Day 5: Delhi Belly

WARNING: The two women pictured above are not as nice as they appear. Please stay away as they are being quarantined and cannot accept any company unless you are a medically trained professional. 

So remember that crazy scene in the movie Bridesmaids when they went to try on dresses right after they went to that restaurant? Yea so that's where me and my roommate, including Elizabeth, have been all day. Poor Jenna and Elizabeth, patient 0 and patient 1 respectively. We all ended up getting medicine and a lot of sympathy/tolerance from the very accommodating hotel staff who tried make us feel less like lepers destroying their lobby common spaces. I ended up getting a shot and was told that I had a liver infection. Although, I'm not too sure how that was assessed other than the super cute doctor's drumming and massage on my abdomen. The good news is that our friendships were fast-forwarded and all boundaries have been crossed today! Ah good times in Mumbai...we're going to make it people!

Courage For MY Business Plan

On Day 6, we also went to the Family Planning Association (FPA) which was invariably referred to as "Fulfilling People’s Aspirations" as well. We learned from the president that they have 42 centers in the 17 states of India! They started in 1952 and have since been an advocacy and access family planning shop to assist women and young girls get necessary sexual and reproductive health care. They use a “five A” framework-Access, Adolescents, Abortion, (HIV)/AIDS, and Advocacy-to make sure that they reach their organizational objectives. They even have a clinic on wheels service that they use to educate and give away medical technologies for hard to reach women that can't come to their clinic. 

The president said that the Indian Constitution provides a lot of things that support the equity of women but it doesn’t translate well in reality as a lot of men AND women perpetuate archaic gender bias. I loved that this organization prioritizes and incorporates gender equity as their guiding tool. It shows how their mission is interwoven and is beyond lip service. He said even in their hiring process, they dismantle the notion of hierarchies by asking at the end of each day “what is one thing that happened well today and what could I have done differently.” This simple question is brilliant because it immediately shifts away from the blaming game among staff relations and everyone is on the same level of accountability. I don’t know how far this carries but in terms of establishing an equal culture, I say they are on to something! 

I asked quite candidly how this organization is sustainable given the conservative Indian politics of sexuality and taboos on abortion. The president said plainly that their mission is to serve women in need of their healthcare and not to talk to the media or incite controversy. He said that protecting and respecting women is something that everyone can appreciate given India's value on motherhood/family. He said, “we don’t support abortion, we promote SAFE abortion!” I think that this was a lesson that really resonated with me and will be something that I really need to hone in on when thinking about my approach and advocacy strategies for my “controversial” business plan. Their approach is obviously working well because they have a myriad of stakeholders ranging from the government to sex workers and religious leaders! He said through donations, the organization is able to thrive and meet the needs of women at a meager administration fee of just 10 rupees (pennies in the U.S.) and that NO ONE gets turned away from their clinic because of pay requirements. Also, we learned that FPA goes into the community to ask folks how much money they would pay for a particular service and what is reasonable subsidized pricing. Again, another brilliant scheme to not only set prices according to the fluctuating economic climate but to also connect and learn what their constituents need/want! 

A really interesting fact about this NGO is that their first meeting was in 1952 and that the brains behind FPA was closely associated with Margaret Sanger (the founder of Planned Parenthood Federation of America).  As you can imagine, their funding stream is just as complicated as in the U.S. as there are restrictions and spending caps when it comes to abortion. Due to the FPA’s overlap with the International Planned Parenthood (as well as the Helms Amendment I would imagine), their foreign assistance aid is minimal. However, most of their money and direct fundraising tactics are targeted at the average woman who doesn’t make a lot of money. Through small donations, more than 60% of their funds come from this target population which in my mind is quite empowering and affords FPA a lot of autonomy and an ability to be transparent. 

We were encouraged and charged by the very prolific and dedicated president with these words: 

“As long as you are firm in your belief, as long as you are doing your best for women then no one, no country can deny you. You will win your case. Just keep smiling and keep going. He also said, “You may be single, but you can also be an army. You all are armies!” 

To prevent maternal deaths; increase access to safe abortion, birth spacing, and contraceptives; to make women utilize and reap the benefits of breastfeeding; and to make gender equity a reality in India....what a SOLID investment in society. I believe FPA is an ambitious NGO with measurable objectives, best practice approaches (peer leaders, street theater in communities, government support, broad allies), and leadership integrity.

7 wide-eyed kiddos

Thursday night brought with it some tummy troubles, which are completely to be expected here in India. When I woke on Friday morning, I wasn’t feeling 100 percent, but wanted to get through the day to learn more about the Society of Nutrition, Education and Health Action’s (SNEHA) work and I am so glad I pushed myself because it was worth it! Our team met SNEHA’s staff members at an urban health center located in Dharavi, the second largest slum in Asia made famous by the “Slumdog Millionaire” movie. Dharavi has received an influx in tourism since the movie premiered, so we were asked not to take photos since it would perhaps tarnish SNEHA’s reputation as a trustworthy NGO (hence the text-heavy post).

When we arrived, SNEHA’s staff talked to us about three of their programs covering the following topics: prevention of violence against women and children, child health and nutrition, and sexual and reproductive health. Perhaps what I was most struck by was the severity of the violence against women that occurs. For example, we learned that many women are literally burned to death if their families are unable to provide a sufficient dowry for their husbands. Or if they aren’t well-liked within their new families, often they are burned to death. These incidences are called dowry deaths and are a devastating reality for women both in urban and rural India (as well as elsewhere in the world). When the SNEHA staff explained these deaths, along with many other cruelties women face such as kidnapping, molestation, sexual harassment, and importation of girls, they also expressed the challenges they face in their attempts to seek justice. Many police officers beat their wives and many citizens here – both women and men – believe that violence against women is culturally acceptable. As a result, SNEHA has started a police officer training to present the concept of gender equality. This way, when they approach the authorities for assistance, they will hopefully be more successful in eliciting a response. These crimes are horrific and underreported, so while it was hugely disturbing to hear about them, I am glad to be informed and even more glad that SNEHA is working to address these injustices.

After the morning presentations wrapped up, our team broke into three groups to observe some of these programs first-hand. I wanted to check out the child health and nutrition program. We navigated our way through some of the streets of Dharavi and arrived at a daycare center, which was a small, damp, and windowless room. Upon entering we were greeted by seven wide-eyed children under the age of three. They were insanely adorable, just sitting there trying to comprehend their new visitors while haphazardly playing with toys. Through studying maternal and child health over the last couple of years, I’ve gained a better understanding of the appropriate growth and development children should undergo. Let me just say that while these kids were adorable (oh, did I already mention that?), they were visibly malnourished. Large heads, tiny limbs, protruding tummies. They were also quite stagnant while we were there, perhaps a sign of fatigue since I don’t know too many two-year-olds who can sit in one place for 20 minutes without fussing a bit. SNEHA identifies these children within Dharavi and meets with their families in a cautious and non-accusatory fashion to recommend that they enroll their kids (free of charge) into the daycare program to better their health. Once enrolled, children spend the day in a room with SNEHA staff members and volunteers playing and they are fed two healthy and nutrient-rich meals before returning home. Most kids are enrolled in the program for a few months until they are no longer malnourished. Parents and families are counseled on healthy eating behaviors as well. While it was a touch disheartening to spend time with these lethargic kids who should have been crawling all over the place, it was great to know that organizations like SNEHA are taking a sensitive and effective approach to help them grow into healthy adults.

After having some lunch on the bus and stopping by another slum to check out a daycare center run by SNEHA for children under the age of five, our team pulled into the Family Planning Association (FPA) of India. Through education, they aim to empower women to take action for their own health. They focus their programs around five A’s: access, adolescents, abortion, AIDS, and advocacy. We listened to a presentation about their programs, toured their facilities and called it a day. So many incredible programs and such little time to digest it all!

FPA staff members shows us an HIV poster in the youth center

Day 9: Impact Making An Impact

Today was a super early day! We met on the bust at 7am to meet the folks at the Impact India Foundation. I loved their mission’s motto wish is: Action today to prevent disability tomorrow. We met with their CEO Mrs. Zelma Lazarus who welcomed and oriented us to their organization’s work over breakfast. She spoke briefly about the fact that they are most renowned for their Lifeline Express train which is a really amazing mobile hospital that provides free treatments and surgeries to those who are poor and disabled in India. The idea of a mobile clinic is something that I’ve noticed even the United States as a best practice for NGOs to impact hard to reach populations. We learned that since the lifeline project was launched in 1991, it has served thousands of people and is sustained by the donated services of medically trained professionals from all over the world. She then quickly shifted gears to talk about the main impetus behind their work which is their community health initiatives (CHI) that includes a model called the “Ashramshalas” for comprehensively educating tribal schools/communities about the benefits of public health. After the introductions at breakfast we got back on the bus and traveled for about another hour to visit the various CHI sites. 

Five site visits:

We first went to the primary school where we saw babies that ranged in age from about 1-8 years. It was immediately a wake-up call for me because I realized that not only were we as students unable to communicate with the tribes but a lot of the Impact staff was unable as well. I then wondered how the rest of the day was going to progress and on a larger scale, how were they going to ever reach their 50% reduction goal for the incidence and eradication of disabilities/preventable disease? We stayed for a while taking pictures and eventually listened to the children sing their national anthem. It was interesting that they had elected classroom officers and a governor that maintained the order. The elected student apparently makes the rest of the class accountable for incorporating their basic health education such as sanitation and hygiene into their daily lives. We left shortly after we realized our presence was making the younger babies cry. Apparently they thought we were going to give them their vaccination shots!

Next, we traveled to the immunization center where we only saw women gathered with their new babies. Before entering the space however, we were blessed by the lead nurse who on most days womans the station by herself. There were at least twenty women packed in the space, some with babies and some without. A few of the new mothers were breastfeeding which was really encouraging to see since one of Impact India’s programs is focused on encouraging breastfeeding for six months. It was so sad listening to the babies cry after their shots. Since a lot of them were malnourished, their screams were very faint. We learned here from the lead doctor of the CHIs that they have pretty thorough medical records’ protocols that is regularly updated and coordinated with the government surveillance team as a measure to ensure that the registered babies have updated shots. We were also assured that the doctor has an outreach team that regularly follows up with the women in the fields to encourage consistency and compliance.

Third, we went to see a health education workshop in session. The teacher was a tribal woman that had obviously been trained by Impact India to share information about various health topics. When we entered, she was reading about the consequences of anemia, how to avoid it, and what supplements/foods are needed to manage it. This session was open to the public but only women attended which I thought was quite interesting as it mirrors some of the trends/public health frustrations in the U.S. We tried asking the women questions about the workshop and how it impacted their day to day lives but they were incredibly shy and/or confused about why we were there. The Impact staff seemed to have a distant relationship with the women so I sensed that our presence made them even more uncomfortable. We did learn however that they had a lot of concerns around prenatal care. The trained facilitator/teacher of the group was able to translate for us that they were mostly concerned about what to do about fertility problems. I kept thinking about how imposing we must have been to this group of women and wished that they were more informed about why we were there. I also learned later that they were embarrassed to talk about their health concerns around men. All in all, I think that good work happens here but I wasn’t sure how they were able to monitor the improvement correlations. It did seem like more of the women attended the health centers to the recommendations of Impact India which is a major plus in terms of meeting organizational objectives.

Fourth, we went to the school for adolescents. There were boys and girls in session but the classrooms were split so we met with the girls. Our goal on this visit was to learn a little about what Impact India was teaching them but also to host our own health education workshop on the importance of nutrition and good pre/postnatal care. This was my favorite site visit because it was engaging, relatable, and I felt like our presence was appreciated and understood. The girls there were very curious about our marriage goals, how we lived in the U.S. and all of our names. It was a give and take discussion thanks to Netra who stayed around to translate our conversation. When they warmed up to us, they even asked how we ate back home and what our daily schedules consisted of between school, life, and work. After talking to them about the importance of having personal goals before committing to marriage I felt less and less enthusiastic about teaching the young girls (6 or 7^th graders)about pre/postnatal care. Luckily, we were able to quickly adjust and decided to focus on the importance of nutrition broadly. We taught the girls a quick song and asked them to sing along. Then we taught them through picture art how water, vegetables, and vitamins can help them grow into strong, beautiful girls. The trend in this school is that the girls have a early and high drop-out rate due to a host of family obligations but largely because the school has no bathrooms. Impact India just got funding to be able to install a toilet dock there which is amazing! And by next year the girls’ studies won’t be interrupted simply because they have their periods during school.  Since they were seemingly impressed by us, we told them that staying healthy and taking heed to their lessons would allow them to be just as impressive!

Lastly, we went to the community health center where we saw how and by whom the community received care. We learned that only two doctors staffed the health center for a population of 60,000 tribal residents!! The doctor seemed very calm and in touch with all his patients but just hearing that the number made me exhausted yet he was happy to take our million questions and didn’t even seem burned out! We learned that the biggest issue for the residents is getting malaria as well as having snake bites since so many of the people work in the fields. He told us that all the care was provided at a very low, subsidized cost- 5 rupees which in the U.S. is less than $1. On a first come first serve basis, the tribal residents come to the center to get minor outpatient surgeries, medications (they have a free pharmacy on site), medical advice, and treatment. If the needs of the patients are too high, then they are referred to and provided free transportation to the main hospital for care.

In all, Impact India had a complex operation that served many functions to improve the tribal community’s health outcomes and dismantle the cultural myths that perpetuate health disparities. Impact India staff used blue hats to gain the community’s trust and to identify who they were. Still, I worried about the overall attitudes of the people. Did they really trust and embrace Impact India’s strategies? Were there any real, cooperative relationships between Impact India and the tribes? I think their mobilizing strategies can be improved by hiring younger staff and putting more emphasis on their each one teach one, train the trainer model. I think this will allow the residents to have more ownership over what they are learning and will inevitably reach their families and neighbors quicker. I look forward to hearing from Sam how this organization really operates since today was so controlled by the staff.  

Three inspiring organizations

After a random and long 55 hours of travel to India our first meetings with social enterprises was a complete success. All three organizations, Under the Mango Tree, Be! Fund and ATMA, were all very inspiring and yet distinct in their social entrepreneurship. Under the Mango Tree was a prime example of selling a good that benefits communities and makes a profit. Be! Fund was about “making heroes” in everyday Indian communities, a program I feel understands the concept of community ownership. In public health the term country ownership is becoming vastly recognized as a needed solution to health epidemics. Be! Fund has taken the concept of country ownership and microcosmic it into community ownership. Acknowledging that people within their own community, not outside influences, know best what changes need to make in order for positive sustainable impact does this.

However, ATMA was the organization that stuck out the most to me. It is an NGO that functions solely to train and assist other NGOs in running and reaching the full potential of their organization. With 3.1 million NGOs in India, it seriously makes me question the status and potential benefit of the majority of them. ATMA is designed to take NGOs that have the potential for high impact but that are not functioning properly and over a year grow them into sustainable organizations. This is an organization I think should be recognized and duplicated across all countries.

Rural India

Today we spent our day with IMPACT India, an organization that works in rural areas of India working to close gaps in health care and implementation. It was a long day that included bumpy roads, visits to schools and health clinics and lots of rain. IMPACT works with the local communities and Indian government to improve the health conditions of the families living in rural areas. Rural India is beautiful, but the people who live there are very poor, most living below the poverty line. They live in areas that are difficult to reach, so they are often over looked.

Our first stop was to an elementary school where we witnessed one of IMPACT’s successful programs. They have implemented a health ambassador model into each classroom. Classes elect health monitors that are responsible to conducting weekly examinations of classmates. These examinations include checking for clean hands, clothes and teeth and asking about aches and possible fever. It was like watching little doctors at work, they were taking their jobs so seriously.

One of the highlights of my day was working with another classroom of adolescent girls at a residential school in the community. We listed as they talking about anemia with their teacher and then we presented a lesson on the importance of good nutrition. All of the girls come from families below the poverty line, so a residential school provides them with daily meals that their family could not. However, many girls drop out of school around this age because of family obligations or even marriage and children. We tried to express to them the importance of staying in school for as long as they can.

At the end of the trip we walked through the primary health center for the area, which covers 60,000 people. We walked through a room where a woman was sitting with a baby she had delivered just two days earlier. It was a girl, her fifth girl. In India, girls are still seen as inferior to boys, so this woman will continue to have children until she has a son. This is just one of the many issues facing the health system in India. IMPACT is working hard to help. In the case of this mother, IMPACT will make sure that her daughter receives all of her immunizations free of charge and will work with her to make sure that she breastfeeds for at least six months.

Today was an eye-opening experience. The families living in rural India have hard lives and often live on much less than $1 per day. However, they get up each day and work hard to make sure that they can do they best for their families.

Hello, monsoon

I am no stranger to monsoons and strong storms having spent many rainy seasons in Hong Kong, which gets battered by typhoons every four months of the year. But I was wholly unprepared to find myself outside in the middle of a monsoon storm in Mumbai.

While shopping with three other classmates in Mumbai’s Bandra district—where the art of bargaining is quickly mastered—we were hit by a sudden torrent of rain and wind so strong I was surprised the shopkeepers’ merchandise stayed put. But they must be prepared for that sort of thing. Many of the shoes on display were, in fact, nailed to pieces of wood. We decided to seek refuge beneath a layer of tarp that one of the stall owners had installed above his display of trinkets and knickknacks. We huddled there for what seemed like an hour, standing on the tiny strip of available walkway between us and the cars speeding by.

What really amazed me was the tenacity of the local people in forging ahead to their destinations, despite the pelting rain, debris the heavy winds blew up, and sloshing through water that became instantly muddy from the dirt and litter on the ground. Most were wearing basic sandals and cotton clothing. For the woman, their saris were able to maintain its usual vibrancy. It was such a sight to stand there and watch the city carry on with its affairs despite conditions that might have driven many people in the U.S. to secure themselves in their rooms until the storm had passed.

Surely, after some time, the storm subsided, the heat returned, and we continued on our way, drenched, a little braver, and a little less fazed.