Journal #4: April Feelings

Hello there. As I said in my last blog, I have been having a tough time since returning from CRHP in Jamkhed. It was an incredible experience and place to be, I think I could see myself returning as an intern in the next few years. The experience also confirmed for me that I prefer rural India to urban India, as I have experienced them. The sense of community is so palpable in rural settings and the power of support really drew me in.

I have been feeling a bit trapped lately in the routines of going to class, doing work, and being at home. I love Indian food but if I eat another potato doused in oil I might cry. I would love to eat a vegetable other than a potato, which I do not consider to be much of a vegetable in the first place. I could maybe shift my thoughts around this small complaint though to see it as part of the thread sewing together a grander, more colorful quilt of this experience. Three servings of potatoes a day definitely create a thick thread.

The potatoes form part of the thread, as does the whistle of the neighborhood security watchman blowing a series of ferociously loud blows throughout the night, the bodies of people pushing through markets, the calls of rickshaw drivers trying to get a rider, the bright colors of women’s kurtas on the train, the strange smells of sewage that settle in the air at night, the laughter of children playing in the park, the constant honks of cars, the pressing of two hands together at the chest with a slight bow of the head, these passing moments and background noise weave the larger patches of my life here together. I feel I am in a unique position of outsider in which I am able to notice these bits of humdrum with a slight fascination, and at this point, appreciation. There is a style of embroidery I have been particularly drawn to in my time here that I believe is called Kantha, in which a running stitch spans the length of the garment, say a scarf, going over any prints or patterns on the fabric. The stitches often have a variety of colors throughout and pop out on top of the pattern of the garment. From first look, the combination of patterns doesn’t seem to make sense, to see so many stitches seems to distract from the beautiful pattern under it, but I have found it to feel incredibly organic and tangible. I like that the stitches and the pattern can clash, feel overly busy, they create a more interesting and detailed piece as a whole. My little experiences each day are the same.

It’s funny now as I reflect on my experience here how certain aspects of life I never considered before coming here are now the highlights of my days. I love taking the metro. I love to just sit and stare out the window at all the different types of apartments, at the clothes hanging from balconies and lines. On the metro I love seeing everyone’s outfits. On weekends especially, families are together and tend to dress up a lot, so women wear their saris, and the metro platform is a rainbow of color. I think I will miss this when I go home. Wearing color is such an intrinsic part of life here and it really does make everything seem more alive and beautiful.

Another unexpected joy is walking around. I have always enjoyed walking, but it’s very interesting to walk in different neighborhoods in Delhi. The Lodhi Colony area consists of huge boulevards with magnificent trees framing the road. Nearly no one walks on these sidewalks and they’re some of the biggest I have seen in Delhi. On a Saturday exploring alone I decided I would walk between my sightseeing spots since getting from one to another was always less than two miles. I enjoyed feeling alone for the first time in a while, but I also enjoyed coming to turn circles and playing a game with traffic as I tried to get across.

I especially enjoy walking in highly congested areas. I went with a friend to a grocery mart type of store that sold foods, cheap clothes, anything you could want, in a neighborhood called Gobind Puri. On the walk back to the metro it began to get dark and the sides of the road lit up with lights shining on clothing, vegetable carts, jewelry. On my right side was rushing traffic, rickshaws and motorcycles whizzing by often six inches away, on my left were the temporary tables filled with goods, and I was in a human tunnel, propelling forward from the sheer mass and density of people. I don’t know what it is about situations like this, but they have been some of my favorites on this trip. For a lot of people, foreigners especially, the idea of touching everyone around you in a crowd while walking down the street would probably feel overwhelming, but I felt incredibly calm, and so happy. I’ve been thinking a lot about these experiences and I think that perhaps I like them so much because I have to be there. I cannot be looking at my phone, even daydreaming feels too far off. I have to be there, in that crowd, feeling the people pushing me forward, seeing the colors of roadside goods, hearing the bikes passing me, and I am a part of it. These experiences make me feel like I am a part of something bigger than myself and like I am actually alive. I find myself now craving this sense of presence.

It’s interesting to reflect on the expectations I came into this experience (and the expectations others provided me) compared to the feelings and experiences I have actually had. With the crowds, for example, so many people told me I would feel overwhelmed. A lot of people said things to me about the number and density of people that implied some kind of wildness or out of controllness to life here. With closer look and I think maybe participating a little more in day to day life, it feels to me like there is in fact a rhythm and harmony to this chaos we assume at first look. There are indeed very chaotic things, things that do not make sense or seem efficient, but I have found a surprising number of things that do make a lot of sense to me. Driving hasn’t felt strange to me in a very long time. It makes sense that with so many cars we are going to pass as many people and swerve around cows as quickly as possible so that we can get ahead. It makes sense that if I am standing a foot behind someone in line, another person will step in front of me and claim that empty space. There are absolutely logics and methods to the way day to day life unfolds. I am feeling very happy that I am starting to understand these things. (Makes me think of one of my very first posts about culture and cultural adjustment and aiming to understand world view, the deeper culture. “Culture is the acquired understanding and values through which we know how to behave and interpret human interactions.” I am becoming able to interpret more.)

I listened to an Oprah podcast with Deepak Chopra, a notable Indian thinker, that touched on some of these exact ideas–– We see and assume chaos, which from our western perspective we might see as a lack of development, but there is indeed a harmony to it all. The podcast connected back to the idea of karma as a fundamental facet of Indian society, which was also very interesting because I have learned a lot about how ideas of karma impact people’s ideas about disease and caste (justify them), but I never considered the idea of karma in terms of just how day to day, public sphere interactions proceed. Essentially they asserted that the idea of karma, whether or not people believe in it, is embedded enough in Indian culture that people live slightly fearlessly and in the moment. Karma literally means action, so you might as well run into traffic to get across the street and put out the energy that you’ll get across, because for karma to come you have to do. This is super simplified and honestly not really an accurate explanation, it’s hard to wrap your head around, but it was interesting to be here and listen to this podcast that puts another explanation to the experiences I have been having.

If you would like to check it out it’s called Creating Harmony on Oprah’s Super Soul Podcasts. https://player.fm/series/series-2372201/deepak-chopra-creating-harmony Just a warning, Oprah is a very aggressive interviewer. I wouldn’t say it’s the best podcast I have ever listened to, but it was interesting.

So I’ve been thinking about life here and how I understand it from my little worldview. I feel like I am starting to understand more and become a little more connected to some cultural norms. I’ve been reflecting on the expectations I came here with, and I definitely, though I didn’t want to admit it to anyone, had this idea that my life would be changed and I would have all these personal breakthroughs in how I know myself. This secret desire feels a bit ridiculous now because I don’t feel different. Can you consciously tell when you feel different? How will I feel when I go home?

There are a few goals I had for myself coming here in terms of personal breakthroughs that I am proud of my progress towards. Part of the reason I wanted to study abroad was to become more comfortable being alone. I am one to surround myself with friends, family, and it’s great! I absolutely love and feel deeply fulfilled by time spent with people I feel comfortable with, but when I got to college I began to feel myself becoming a bit too dependent on the presence of other people. FOMO is real, and I was starting to become alarmed at the extent to which I was feeling it. Shipping myself alone to a different country seemed like a possible solution to this discomfort with myself, and yes, I would say I have gotten a lot better with it. I tried especially hard not to reach out too much to people at home to cope with the initial homesickness, shock, you name it I was feeling. I started taking walks, during some of which I would talk out loud to myself to have a conversation and work through whatever I was feeling. I journaled at ridiculously high rates for a while, which really helped me connect with my feelings and sort through them, but then even that felt a bit too dependent, and eventually I found myself able to spend time with myself as a form of soothing. Normally I would look to the people around me to express my feelings, then when I didn’t have them accessible I started using my journal, and now I am able to sit and think a little more. A big aspect of my FOMO I think actually comes from a fear of being alone with myself. Right?! Like how much time do you actually spend not interacting with another person but yourself. It is scary! I am not sure why, perhaps just more insecurity, or maybe out of ease? It’s so much easier to use and to need external sources to provide comfort, to feel loved and taken care of, so I tried to start doing that more for myself. I don’t think there was any particular action I took that helped me work towards this goal, but I think that being here and being relatively alone helped do it for itself. I think that what I have come to understand in feeling this shift is that I have to be comfortable being in discomfort. Instead of finding a distraction such as a person to listen to my woes or hold me, I had to sit with my discomfort, acknowledge it, and somehow find a way to be comfortable in it. This felt really brave and really new to me, and it felt uncomfortable! Vulnerable! But those feelings always ended up passing, so I think it was a good exercise. I am hoping to carry this forward with me.

I’ve been reading this book called “The Places That Scare You” by Pema Chodron, an American Tibetan Monk (?), that is allllllllll about the practice I just described. So in Buddhism there are three main principles of human existence: impermanence, egolessness, and suffering/dissatisfaction. Impermanence and dissatisfaction easily make sense: life is hard, nothing is permanent, and this sucks! Everything is constantly changing, right? Trees are growing, air is moving, the cells in your body are doing things, the thoughts you think are never exactly the same, you are never exactly the same. BUT, we resist! We do not like change! I absolutely am horrible with change! So what if I begin to consider that everything is in constant process? I am always in transition? If I know this, that even in the moments I feel most still and stable, I am changing and the world around me is changing, then perhaps the bigger feelings of transition I feel will be less scary. My uneasiness of not knowing what’s going on can be met with the acknowledgement of the constant waves of transition that are moving in me. I am learning each day, I am getting a wrinkle line on my forehead, I am becoming more comfortable being alone with myself. I have to open myself up to notice these small changes because even if they are small, they carry feeling! I must acknowledge the little feelings of joy, love, but also the rawness of pain, embarrassment, loneliness, gratitude. And when I acknowledge the feelings, I can see how they come and go. I can see that they are not permanent. I can see how I change. Flexibility and openness comes from getting to know our fears well, such as those of change, and ultimately bring us strength and peace.

So maybe feeling all these feelings I am having alone, the little changes, letting the emotions I feel exist and acknowledging how they feel, is a part of the grand fantasy of change I envisioned for myself. The more I tune in to the subtle shifts within me the more I feel a tenderness towards myself that I did not expect. To feel this tenderness is scary, I feel open, but I feel awake. I especially enjoy walking in highly congested areas.

Blog #8: Nearing the End

Hello! I am in Delhi until Friday and then I head off to the mountains to complete a four week independent research project! Can you believe it? After coming back from a week at CRHP in Jamkhed I felt very downtrodden. To be honest, I am not particularly inspired by any of our lectures lately (it’s hard to inspire after CRHP) and I have reached a point of frustration with my program. Academically, it isn’t what I expected. I have learned a lot though, and I have enjoyed all of our excursions the most (Bahraich, Thailand, CRHP). I am feeling ready to head to the mountains and be on my own. I think the experience will be very transformative and possibly the best part of this program. We will see…

I wrote the following paper as a sort of synthesis/summary of some of the major things I have learned this term. I pumped it out in a day so it ends in an unusual metaphor as a final attempt to marvel my “teacher,” (angry because he was not a good teacher), but, I think it is a pretty decent analysis of some of the aspects of being here that to me were the most significant. I hope you enjoy :)

The World Health Organization in 1978 redefined “health” as  “a state of complete physical, mental and social wellbeing, and not merely the absence of disease and infirmity.”[1] This definition increased the responsibilities of governments to recognize the greater factors that play into a population’s wellbeing. “Health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”[2] A healthy population is no longer determined by markers of birth or mortality, but by the social and economic status of its citizens. Section Three of the 1978 Alma Atta Declaration declared that the attainment of health can only be fully achieved if economic and social development increases in concurrence.[3] The concepts of social and economic development in India include factors such as gender, caste, poverty, geography, and education. These factors exacerbate levels of health, unless education is available. Education is a facet of health because of its capacity to improve the physical, mental, social, and economic well being of individuals.

In the discussion of health and education in India, gender is inherently an aspect of access to health. Women are generally repressed as India functions majorly as a patriarchal society in which the role of women, more so rural women, is to produce children and care for them and the home. When a mother is not valued, her health is at risk, as is the health of her child. Direct impacts of sexism on health include sex selective abortions, in which fetuses determined to be female will be aborted because the family wants a male child, and high rates of maternal mortality as the mother often does not stay in the hospital long enough after birth because she must return to her duties at home.[4] These factors are clear discriminations against women’s health. There are also a number of factors that are socially constructed through traditions and norms that are dangerous to women’s health.       

In India, forty percent of women’s marriages occur before the age of eighteen. The desire to marry off a daughter at a young age comes from the beliefs that she cannot contribute to her family, so the only option for her and the only place she will have purpose is with a husband so that she can produce more children. Because girls are not seen as able to contribute to the family, it is preferred for boys to go to school. The decision of whether a girl goes to school lies in the hands of her family. There is little to no dialogue between men and women about their issues and needs––women, let alone young girls, lack decision making role in their lives. When a family chooses to marry their daughter, before or at, the age of eighteen, that girl is not fully developed physically or mentally. In addition to her physical and mental development, if a girl is married at the age of fifteen and becomes a mother at sixteen, there is no feasible way of finishing an education. Fifty-three percent of women become pregnant before the age of twenty,[5] which enforces the social structure that discourages women from gaining greater knowledge, which ultimately functions as access to social and economic well being, and a greater state of health.

        The education of women as a crucial determinant of health is a strong theme in literature as well as in real-life experiences. Shoba, a village health worker in Jamkhed, Maharashtra, explained in an interview how an education provides more than an avenue for a job, it provides changes to every aspect of an individual’s life. In fact, Shoba said that when a boy is educated, he will learn to treat his family better, but when a girl is educated, her entire family will do better. The education of a woman gives her knowledge, thus power, in practices of child rearing, nutrition, sanitation, and finances, and increases the likelihood of her children receiving an education.[6] The betterment of a woman’s life through education extends further than in her traditional roles of womanhood. The education of a woman breaks socially constructed expectations of her role in society and ends cycles of repression.

Breaking the cycles of how women are viewed in rural Indian societies might seem to be a long-term mission, but in actuality the positive benefits of education are evident within generations. Shoba, now a middle-aged village health worker, was the oldest child in her family. As the eldest she was unable to attend school because of her duties to help with younger siblings and the home. At the age of ten she was married, then had her first child at fourteen. When she was twenty years old she became a village health worker, a position in the community, which required a year of training, educating Shoba about health, providing her skills to care for her community, and eventually share the knowledge she gained with the community so that they too could benefit from a greater knowledge of health. When asked how she has changed since becoming a village health worker, Shoba said, “I don’t have any deficiency…I can do anything and everything.” The fact that this was the first response to the question of changes Shoba had experienced in her life implies that before becoming a village health worker, Shoba did feel that she was in some way deficient. Before she had the training and position of health worker, she did not believe she could do “anything and everything,” but access to knowledge allowed Shoba to “become more aware” of herself. “I’m not educated but I can talk to higher officials about anything…I’m not afraid of anyone now.” Shoba’s beliefs about her capacities directly counter the beliefs she was raised with, that she had no voice and no role besides that of a mother. The power of education allowed Shoba to reconstruct her understanding of her role in society, and to break the cycle of feeling deficient. Shoba proudly shared that she decided to get a driver’s license because, “If men can drive then I can drive,” and bought a tractor and land to farm, creating financial independence from her husband. She also shared that some people in her village are jealous of her, suggesting they would want the same successes knowledge has brought. In addition to this information, Shoba shared that her children all went to school and now her grandchildren attend boarding schools. These stories of achievement are markers of financial and social change in her lifetime, as a consequence of her education as a village health worker. Shoba’s education has created tangible change within her own lifetime and stands as a testament to the power of knowledge in a woman’s life.

In the case of Shoba, and other village health workers of the Comprehensive Rural Health Project NGO, the power of education on a family’s social and economic well-being, and consequently their health, has been realized. The Indian government recognized this more comprehensive approach to health more recently, in 2005, when the National Rural Health Mission was created. The National Rural Health Mission (NRHM) recognized that India’s health care systems must focus on vulnerable populations. The poor are most at risk of bad healthcare systems and treatments, and spend comparatively more money on healthcare than urban populations.[7] The conditions in which people work, live, and grow are cited as the leading causes of the inequitable distribution of health. These conditions of life are, in other words, the factors of gender, caste, poverty, geography, and education that systematically divide and oppress the population. The NRHM recognized that these conditions of health require broader solutions, “pro-poor policies,” to “tackle” the inequitable distribution of money, power, and resources in India.[8] Thus, the Indian government set forth a series of actions. The government established the right to food and right to education for all children in 2009. The government is obligated to provide and ensure the education of all children ages six to fourteen.[9]

The government, though expected to be accountable for resources such as education, often fails to provide to the degree the people actually need. It is when the government leaves gaps that the work of NGOs can be incredibly beneficial in providing resources. An NGO is beneficial to the population it serves when it acts as a source of knowledge. According to Dr. Anjali Capila, a good NGO provides links between citizens and the socio-political process, is committed to individual and community awareness building, and the process of “community building” includes the participation of those who cannot or usually do not participate in communal decisions and actions.[10] These characteristics of a good NGO all follow the common theme of encouraging responsiveness in communities. Awareness building, as Capila says, is essential to empowering the community and inciting change. Awareness is achieved through the sharing of knowledge, the process of educating.

The Comprehensive Rural Health Project NGO works to share knowledge to educate the communities it works with. Jayesh, a social worker at CRHP, said in an interview that his role at CRHP is to “expand knowledge to grassroots workers in the field.” “People always respect knowledge and information,” so when he shares information, people listen. Jayesh has worked to disseminate knowledge through programs at the CRHP such as men’s groups, women’s groups, and adolescent boys’ and girls’ groups. At these group meetings villagers, many of whom do not have a formal education, are encouraged to bring topics they would like to know more about. CRHP also organizes topics for the groups surrounding health, farming, and financial practices that raise awareness in communities. The village health workers play a major role in the spread of information to villagers. Surubai, a village health worker, organizes group meetings for her village to educate about government schemes the village would otherwise be unaware of. There are numerous government resources which fail to be realized by citizens simply because the government fails to propagate them. The failures of the government can come from a variety of factors such as corruption, bureaucracy, lack of efficacy, or the lack of resources. Citizens often have to ask their governments for services to be provided, which is unlikely to occur if they don’t know what the government should be providing them in the first place. When Surubai learned about all the possible government schemes, she initiated a nutrition program in her village for malnourished children and started a bank for women to be able to take loans and start income generation businesses. Surubai herself started selling chilies and earned enough money to buy land on which she dug a well for her village to have accessible drinking water. Through Surubai’s training and the knowledge she gained about government proceedings, she was able to change her own life, but also the entire economic and social wellbeing of her village. The power of knowledge in a woman’s hands is strong.

The village health workers of CRHP, as community members and women, occupy a unique role in changing the realization of health for rural Indians. These women are using their knowledge and awareness to stop cycles of caste and gender discrimination. One village health worker was not invited into higher caste homes to provide her services because she was of the Dalit caste. Higher caste villagers did not believe a low class woman could hold useful knowledge and would not let her offer them medical advice. Then, one day, a high caste woman went into labor unexpectedly. The woman’s mother begrudgingly called for the village health worker, who had to enter the home on a path of cloths so as not to touch anything. The village health worker gave the woman going into labor a check up and said she was safe to deliver, but the woman’s mother did not believe her. The woman’s mother called a local physician who came and told the family the pregnancy was high risk and a Cesarean section would need to be performed immediately. The village health worker urged them not to believe this doctor, she knew the pregnancy was safe, and instead convinced them to come to CRHP’s hospital. Upon arriving at the hospital, the pregnancy was indeed deemed safe and the village health worker delivered the baby. The village health worker used her knowledge to prevent this family from being exploited by a greedy doctor. From that moment forward, all the higher caste families in the village came to the village health worker for help. Caste is likely still a social factor in the village, but this village health worker created waves of change in that her identity as a low caste woman became a second thought compared to her identity as a source of knowledgeable in the village.

There are many cases in which local medical professionals and unqualified professionals will attempt to exploit poor, rural citizens. As seen in the story of the C-section, the knowledge the village health worker had was able to prevent a poor rural woman from being exploited. Rural people are much more likely to receive care from unqualified providers so the dissemination of knowledge from village health workers and NGOs plays a crucial role in advocacy against such care.[11] A social worker at CRHP, Madhu, explained how desires to exploit poorer populations come even from within communities. When he first started to work for CRHP, his primary role was to organize Young Farmer’s Clubs (YFC) that act as a support and education group for farmers in villages. When the wealthier populations of the village heard about the YFC, they were outraged and fought against its creation. These wealthy people did not want farmers and workers to become organized because they wanted to continue to benefit from the low cost work of uninformed villagers. As YFCs formed, poorer farmers were able to work together to buy equipment to share within the club, as opposed to renting equipment at high rates from wealthy farmers. Citizens who are knowledgeable about their rights and options are indeed dangerous to those in power because they have the capacity to stop these people in power who benefit off their oppression. As farmers become involved in groups, learn, and support each other, they become stronger as a system and find more success economically and socially. The knowledge they gain allows them to live altogether healthier lives.  

When asked what he likes about working with CRHP, Madhu said, “My happiness is that my knowledge is not only with me; I am sharing it with everyone.” The phrase ‘knowledge is power’ is no cliché in matters of health, gender, and socio-economic wellness in rural India. Education, be it through school, the training of an NGO, or community outreach, prompts social and economic development which forms the foundations on which greater health can be achieved. The achievement of health through education is clear in the story of Surubai, who used her knowledge of government schemes to build a well for her village, and the village health worker who protected a family from an illegitimate doctor. The knowledge village health workers have gained has a direct impact on their lives but also all of those around them as their children and grandchildren go on to gain educations, and families in the villages begin to change and inevitably inspire change in their communities. Awareness building places knowledge in the hands of the people, so the unequal distributions of power may begin to shift. The most important aspect of awareness building is the fact that to have knowledge and incite change does not require having a degree. The power of knowledge can be placed in anyone’s hands. The provision of knowledge to rural women and communities improves health outcomes like a well: At first the effects of the information begin to seep out as droplets of water, puddles, in certain key, drilled locations, but over time the water of knowledge and change will begin to flood.

Blog #7E: Friday at CRHP

Friday March 29, 2019

Major Events: lecture on role of mobile health team, hearing stories of village health workers

                1. Mobile Health Team

        We had a lecture with the mobile health team, which functioned more as a question and answer session to learn more about what they do. As discussed previously, the MHT acts as a liaison between CRHP and villages, organizes/leads groups, and leads trainings at CRHP. The MHT told us that currently, CRHP has 40 active project villages they are involved in. Apparently villages used to be against the care of CRHP because they thought the organization was going to try to convert them to Christianity. Now there is a waiting list of villages that would like CRHP to work with them when resources are available. As said before, villages generally take 5-7 years to graduate from CRHP, and it is when a village graduates that a new village can be taken in. If a village wants to work with CRHP, they will approach the MHT, who will set up meetings to determine what the village wants and needs.

        When a village has graduated the program, the MHT will routinely conduct surveys to determine the status of health issues over time and how well the village is maintaining practices. While CRHP is involved in a village too, the MHT keeps records. MHT member Madhu Ji showed us hand drawn maps of villages that mark homes with the immunization status of family members. The map also acts as a method of maintaining privacy so that if a MHT member is going into a village they don’t have to ask around to find someone’s home, raising attention to the person, but instead they can go in knowing the location of the home they are visiting.

        The last thing the MHT told us about were spiritual healers, often called quacks. Madhu Ji put on quite an impressive act of playing a spiritual healer. He cracked a coconut and black soot came out of it. He predicted if one of our group members would have children by lighting a piece of paper on fire and rubbing the ash on his arm (it was crazy, two stick figures of little boys appeared on his arm). This presentation is given to community members and groups to show that these spiritual healers are using magic tricks to give health counseling. It is a very interactive and captivating way to teach.

        2. Stories of Village Health Workers

        We met with four village health workers: Surubai, who had been a VHW since 1984 and delivered over 600 babies, Babai, a VHW since 1993, Surekha, a VHW since 1997, and Akila, a VHW since 2012. These women took the time to tell us their entire life stories, it was an incredible privilege and really quite moving.

**I will write these stories up later, I want to do them justice and thoughtfully decide which should be shared or not

Reflection: A major theme in talking with village health workers was that become a village health worker completely changed their lives. The women told us how they never expected to be treated with respect in their communities, nor to have such knowledge and opportunities, and now they boast of the places they have visited, the saris they own, and the successes of their children. CRHP does indeed change lives. These conversations reminded me of something Dr. Ravi said, that most of what CRHP does that is advertised is the surgical camps. Donors like to see the camps because they are flashy and impressive, but Ravi said these camps are only 10% of what CRHP does. The real changes and the real accomplishments are in the lives that individually change, such as those of these women, which cause waves of change in their own families and communities. You can’t measure empowerment so it isn’t what CRHP is necessarily known for, but that’s what they do.

Saturday March 30, 2019

Major Events: tour of hospital

      On our final morning we had a tour of the CRHP hospital. The hospital has cut down significantly on staff as the government hospitals have become reliable. The hospital hosts surgical camps four times a year, in which surgeons from around the world come for a week and perform up to forty surgeries a day, pro bono. Community members in need of surgery, often burn or accident victims are able to receive free care. Apparently many surgeons are shocked by how simply operations can be performed, which Dr. Ravi told us is one of his major qualms with modern medicine­–– surgery can still be safe and effective without all the regulations and technology that exists in the West.

Blog #7D: Thursday at CRHP

Thursday March 28, 2019

Major Events: Visit to village, meeting with women’s self help group meetings, visit to CRHP farm, met Ratna Ji

                1. Meeting with Self-Help Group Leaders

        Today we met with leaders of women’s self help groups in a nearby village. As an interesting tidbit, before the meeting we were sitting and Goutam Ji was playing with a little girl. When he asked her name, she said Avanchita. He told us quietly that in Marathi this name means “unwanted.” Then someone told us that she had recently been renamed by her grandmother, Asmeta, which means “esteem.” She is very young now but her family has begun to call her by this new name.

        Our meeting then began with the women’s self help group leaders, Jayesh Ji, and a government worker who is responsible for organizing 570 self help groups in 87 villages. The self-help groups are different than the “women’s groups” that CRHP leads. These groups’ primary roles are for women to have financial resources. The groups of ten to twenty women contribute 100 rupees per month to a pool from which members can take out loans. The reason the group is paired with government action is that they also get money from the government and can take out much larger loans. The women keep records of the money and all sign their names or give a thumbprint if they cannot write. This record is a big deal and all the leaders were very excited to show us their record books. It is very new in this area for women to be able to keep records and be in charge of finances. Even to contribute money monthly and sign your name is a huge deal because it symbolizes ownership and independence. We got to ask the women a lot of questions, and it was very cool because more and more women kept arriving. We started with about four women and by the end of our talk there were around twelve. As new women arrived Jayesh Ji would ask them our questions so they would be included in the conversation, which I really liked. One of my classmates asked if the group functions as more than a meeting and money lending space, if it is a safe space for women to simply be together and talk, and all the women immediately smiled and some got very excited by the question. One woman said she always looks forward to the group to talk and catch up with others. It is their time alone and in charge, when they get to tell their husbands to watch the children. One woman said, “That’s our one hour of freedom.” I asked if anything has changed in anyone’s life since they’ve become self-help group leaders. One woman said that she feels generally more respected in the community. Another woman said that once she went to the bank and a man was very disrespectful to her and so she yelled at him, “Do you know who I am!? I am a self help group leader!” Apparently the man was very embarrassed and then came back to her to apologize. Other women said they are happy to have access to money. Another classmate asked both the government official and the women what their ten-year goals are for the groups. The government official, a man who I actually quite liked from what I could gather from him, said he wants no one to be below the poverty line and for all women to feel empowered. He seemed very sweet whenever the women were telling stories or answering our questions he listened very intently and smiled. I liked him. The women said that they are going only up! Right now, they said, they are focusing on themselves and taking care of themselves, but their goal is for their groups to be able to take care of others too.

Reflection: Meeting these women was an incredible privilege. There is a slight bitterness to know that the positive feelings they have about the self-help group and themselves has come for many of these women through just one hour a month. But it is also amazing how powerful that one hour a month is. I think that the responses the women had to our questions speak for themselves and speak volumes.

        2. Visit to CRHP Farm

        The CRHP is currently not fully operational, as there has been a drought, but the worms are alive and doing well. I found the worms exceptionally exciting. About 15 years ago Monsanto began selling cotton seeds, including the fertilizer and pesticides, as a bulk package. Everyone was thrilled because the seeds produced a great crop. Over time however, farmers had to keep using stronger fertilizers and pesticides. The fields were being worked too hard. In addition, farmers had to buy new seeds every year. These factors compounded to become very expensive and many farmers went into debt. The state of Maharashtra is now has the most farmer suicides in all of India.

        CRHP recognized that farming is a key livelihood and needs to be sustainable. Not only sustainable, but organic. One solution to buying fertilizers is to produce your own. Thus, the worms. CRHP has an area that is covered with tarps, and in the ground are concrete troughs 25 feet long by 4 feet wide. There are a total of six or so troughs lined up, filled with soil. This system is a sustainable fertilizer loop. Two troughs are filled with worms, natural decomposers who break down the soil and add nutrients. It takes twenty-one days for the worms to work their magic, and then the soil is ready to be used as fertilizer. I am not exactly sure about the steps to the process, but I know the old soil gets looped back in, cow manure is added, and eventually the worms. At a certain point as well the process can become continuous so you will always have soil ready to use. Most farmers in the area have about three acres of land and a set up of 10 by 6 feet of the worm system can provide fertilized soil to three to five acres. At first people were wary of this system, but over time people began to see how affordable and effective it is. Now there is a waiting list of people who want to learn how to make their own organically fertilized soil. Another fun fact is that CRHP has given various villages and farmers worms as gifts so they can start the process. CRHP will sell the soil they make as well, at a highly discounted rate so it is accessible to farmers. The farm used to have goats, poultry, and many crops but because of the drought it is not fully operational.

        3.  Meeting Ratna Ji

        Ratna Ji is the manager of the CRHP farm. She started working on the farm around 2001 after receiving care from CRHP. She had a very difficult life and had nearly nothing when she came to CRHP for treatment, so in exchange for her treatment she was offered a place to stay and work. I will not write Ratna Ji’s story here right now because it was very personal and emotional.

Reflection: The fact that CRHP has a farm is so amazing to me. Yes, that is holistic healthcare! It is so cool as well that the farm functions in response to the direct needs of the area. Fertilization was a problem, so the farm found a sustainable solution to model and then share. Hearing Ratna Ji’s story was insanely moving and made me think how many lives CRHP has changed. Not only that, but also how many insanely strong women I have somehow been lucky enough to meet. The fact that she offered to tell us her story was so generous I would say, to share and relive certain pains, and now to be thriving and accomplishing so much. She told us that last year she went to Switzerland to receive an award and apparently a Bollywood movie is going to be made about her!? I feel profoundly honored to have met Ratna Ji and to learn about her worms.

Blog #7C: Wednesday at CRHP

Wednesday March 27, 2019

Major Events: Walk through slum, preschool pickup, shadow preschool, lecture on factors of health, lecture on communicable and non-communicable diseases

        1. Preschool Pickup

        Today we did preschool pick-up with Meena, the CRHP preschool teacher! There is a slum right next to CRHP called Indiranagar which CRHP has no presence in. Indiranagar has never been able to organize or mobilize and reach out to CRHP for a partnership. The community has a large migrant population that spends half of the year working at a sugarcane factory. There are some sewage tanks that CRHP installed, but aside from that the NGO has no presence in the slum. Thus, they decided to build a preschool outside of the slum that families could send their children to. The primary reason is to provide food. The preschool provides two meals per day to children ages two and a half to six years old who attend. Students can begin to attend at any point in the school year, the only requirement is that their parents give them a bath in the morning before school.

        We walked around the slum to pick up students before school. Every day Meena Ji walks through the slum to collect children whose parents can’t take them or who are too small to come alone, but the deeper purpose behind her daily walks is to raise awareness and encourage families to send their children to school. When walking around, Meena is able to identify new families who have returned from the sugarcane factory. As we walked around she would call out to families and say “Send your kids to school.” Or “Tomorrow when I come by have your children washed and I will take them to school.” She said about 70% of children in the slum come to preschool. When children come to preschool it is more likely that they will continue onto primary school and stay in school for a significant time.

        The slum has various levels of development. Some homes are big and nice, some are shacks with open sewage ditches. There is a big problem with alcoholism in the slum. We walked past a few families that were drinking and gambling (it was nine am), and Meena said these families generally will not send their kids to school. We picked up a very cute brother and sister pair first. The little girl was so sweet she had a ponytail on the very top of her head so her hair popped up like a fountain. She immediately held our hands and pulled us on our way to the school. We stopped by another home where a little girl was crying because she couldn’t go to school. Her parents were afraid she had an infection and didn’t want her to leave the home. They had another child who had died from an infection. Meena immediately called the mobile health team and requested them to set up a time to take the little girl to the hospital to be checked. Even though the MHT does not regularly check on Indiranagar, the resources of CRHP are always available. Meena decided that the girl seemed well enough to come to school, so she came skipping and jumping the entire way. We picked up about seven more kids and then headed off to school.

        There are around forty kids who attend the preschool. We started the day in a big circle, singing songs and moving a bit, then we did the alphabet, and then was playtime. After play time the kids had a breakfast time. They all went into a separate room to eat. It was very sweet they all line up to wash their hands and then they serve each other! Meena scoops the food onto plates and then these tiny little people serve their classmates before they sit down and eat themselves. It was very sweet. The meal was a porridge, couscous like grain with onions and herbs in it. I really liked it. The kids also have water and can have as many helpings as they like. We only stayed through this meal, but I definitely think this visit was one of my highlights of the week.

        2. Communicable and Non-Communicable Disease Lecture

        The major communicable diseases that used to afflict the Jamkhed area are leprosy, tuberculosis, and Guinea worm. In the past, when someone began to see symptoms of leprosy they would go to a faith healer. As the person failed to get better, the community would call them a “bloody person” and eject them from the community. The person was completely outcast–no food, no socialization–and they were essentially left to die in a hut. Leprosy was considered a curse justified by reincarnation; if you did something bad in your past life you had leprosy in this life. When CRHP began to treat people with leprosy it was very difficult because of the cultural meanings surrounding the disease. People believed that a goddess had given the curse, so when doctors said, “No, this is a disease that can be treated with medicine,” people wouldn’t trust them. So, doctors had to make the treatment fit into the religious ideas of the goddess and the curse. I am not sure exactly how this was done, but Jayesh Ji said the health teams “sugarcoated” the information about the treatment to be somehow supportive of the religious ideas. Eventually people began to recognize the power and efficacy of medicine. Aside from treating the people who had leprosy, CRHP offered support and counseling. People were taught and encouraged to cover their hands and feet with cloth when they were doing work to protect their limbs, which were more sensitive. As CRHP initiated these missions, people suffering and recovering experienced more support from their communities and were no longer sent to institutions or sent away to die.

        Tuberculosis had a similar stigma in communities, and the community rejected people with confirmed TB or signs such as coughing blood. The Village Health Workers used to actively check villagers for TB, going door to door and administering tests. If someone was determined to test positive, they would be treated in secret to prevent the stigma. TB has a very high risk of relapse because the treatment is 18 months and generally people begin to feel better within the first month and stop taking medicine. It is for this reason that VHWs were highly responsible for visiting patients every day and administering medicine. The Village Health Workers we met with, Lullamby and Asha, said they had saved 21 and 18 people from TB, respectively. A few interesting facts––CRHP used to get TB medicine from friends’ connections in other countries because they couldn’t rely on the government. Now of course TB is essentially eradicated in this region and if someone were to be diagnosed the government would be responsible. Another interesting fact is that if someone had TB they would be told to put a cloth over their mouth if they were going to kiss anyone. This was a strange and funny fact. The best part about learning about TB was that the VHWs and Jayesh Ji sang us a tuberculosis song. The song is sung at women’s group meetings and essentially tells the signs and symptoms of TB.

4.     Non-Communicable Diseases Lecture

        The rates of communicable disease are very low now that proper sanitation, nutrition, and resources are generally available. Instead, India is beginning to face the crisis of non-communicable diseases of diabetes, cancer, and high blood pressure (cardio-vascular diseases) that arise as the population ages and changes in nutrition and lifestyle occur.

        Diabetes is becoming very common because of lifestyle and heredity. Especially if someone was malnourished as a child, their pancreas might not have developed enough, and thus as an adult they are unable to produce appropriate insulin. In the 1990s, sweets and junk food were introduced to India for the first time (India’s economic liberalization occurred in 1991) and companies actually made smaller packets so that people even in poverty could buy chips, candies, etc. It was during this time that liquor also began to be much more prevalent.

        The most common cancers found in the region are oral, skin, uterine, and breast cancer. The oral/mouth cancers are directly correlated to a high use of tobacco. The causes of uterine (and I think they meant cervical) cancer are very interesting because they lie in direct relationship to sanitation.  Apparently if a man is not adequately cleaning his foreskin, HPV can develop and then is transmitted to the woman. Another cause for cervical/uterine cancer surrounds sanitary practices during menstruation. Because there is such stigma about menstruation in rural India, many women will wash the cloths they use when menstruating in secret. This often implies a stressed environment so the cloths are not adequately cleaned, nor are they able to hang out to dry. Women end up using dirty or wet cloths, which can prompt infection. In areas with even more stigma around menstruation, women will use ash or even cow dung in the place of a sanitary napkin. We did not talk more about solutions to this aside from educating women and men about sanitation, I wish we had discussed in more detail.

Reflection: I enjoyed the preschool pick up most, the one little girl we picked up was so full of love with the chubbiest cheeks, I definitely needed some of that love. In terms of a more critical reflection, it is incredible the Meena walks through the slum every single morning to pick up kids and to try to get other families to send their kids to school. She said at one point that if she didn’t walk through each morning some families just wouldn’t send their kids, her presence is crucial. I found it surprising that there are still an estimated 30% of families who aren’t sending their kids. It is free childcare and food, six days a week. But still, the value of education is not always recognized. I also found it really cool to discuss communicable and non-communicable diseases in context as opposed to in a classroom. Technically we were in a classroom, drinking chai and discussing how men must be taught to clean their foreskin, which was an interesting moment, but the relevance of what we were learning was so tangibly close. With the closeness of the topics we were discussing too, I found myself slightly bothered that these issues still exist. Cholera has been wiped out, no more TB, no more leprosy, but men are not cleaning themselves and some women are using ash as sanitary napkins! Like I said, I wish we talked more about this and I wish in the moment it occurred to me to inquire more

Blog #7B: Tuesday at CRHP

Tuesday March 26, 2019

Major Events: Visit to village Kusadgaon: school, walk through village, meeting with village health worker, meeting with CRHP Interns

        1. Visit to Kusadgaon

        Our first event of the day was a visit to the school in Kusadgaon. As we walked up the school children were doing morning sing along exercises outside. The teachers had a few students speak to us in English and do little dialogues together. It was really cute. Then we had a meeting with the teachers. They told us about the changes in the school and said the village has a 100% rate of attendance of children. I asked if any children drop out or don’t come to school and they said no. They also said the biggest change they’ve seen has been more girls coming to school. This was a little confusing to me because if they keep seeing more girls coming to school then I do not think 100% of the children in the village come to school. We saw the preschool and Anganwadi worker. She showed us the government supplements that are given to pregnant and lactating mothers, as well as families with young children. The government provided food to the Anganwadi worker to feed the preschoolers is cooked by the women’s self help group of the village, which is an interesting fact. When we were walking around the village we saw various men carrying the packets of dietary supplements home, so it was cool to see them being used.

        After visiting the school Bebitai, a “retired” Village Health Worker, took us for a tour of the village. Kusadgaon is a project village, meaning that CRHP has been involved. I believe the village has graduated, which means CRHP is no longer actively involved and the community has sustained the practices initiated with CRHP, because CRHP first got involved around twenty years ago. Normally a village takes 5-7 years to become self-sustaining and “graduate” from needing CRHP’s direct care. CRHP installed sewage pits for each home twenty years ago to eliminate sewage in ditches beside the road, which are major causes of disease. Now, every home has a toilet. One family’s toilet was even on the roof because they didn’t have room inside their home. The streets are paved and chalk markers on the doors label how many kids are in a family and which vaccinations they have completed.

        Bebetai invited us into her home (the home of her mother technically), where she showed us how to conduct a urine test for diabetes. Over a small fire in her living room, she was able to heat a test tube of urine and Benedict’s Solution and the color change in the solution would determine the percentage of sugar in the person’s blood. Bebetai is uneducated but able to perform this test, along with many others, that can have immediate impacts on a person’s health. She also tests blood pressure for us. Bebetai had two children but her husband was an alcoholic so she left him and moved back home with her mother. She was very proud to tell us of her children’s and grandchildren’s accomplishments. Even though she has technically retired from being a village health worker and a younger woman has taken her place, she is still very involved in health and leadership matters of the village.

        2. Meeting with CRHP Interns

        It was especially fun and nice to talk with the interns at CRHP. They are all just a few years older than us. The role of the interns is to help CRHP run smoothly. They do a lot of computer work such as grant application writing, social media posts, statistics and data entry, and fundraising. They are in charge of visitor logistics, orientation, and tours. During surgical camps they are very busy coordinating surgeons, surgeries, recovery rooms, etc. One of the interns, Chase, told us that she especially likes that CRHP is totally sustainable. Most staff members can do multiple jobs, the mobile health team is completely on top of all their programs, and the village health workers once trained are set for life. She said an especially important thing as an intern is knowing you are helping make things easier and more efficient, but that you should never overstep your boundaries and do something that could make the role of intern more important. For example, she said once she was taking pictures at a gauze removal and a nurse asked if she thought the stitches should come out. Chase said that while technically yes, you could answer this question, you should not. Even if you are a nursing student who knows the answer, you must tell the nurse "No, I don’t know, you know.” Especially because the interns are from America, many people assume they have more knowledge or credibility and will ask them questions like this, but it is important to always make sure your role is not one of decision-making.  

Reflection: Visiting the village Kusadgaon was very interesting because you could definitely tell that it was doing well. My point of reference was the village in Bahraich, which also had sewage tanks for example, but Kusadgaon’s streets had a much more active energy of cleanliness and ‘put-togetherness.’ I personally was very moved by how involved the community is in continuing the work of CRHP. Bebetai said that there haven’t been communicable diseases in years and as new initiatives within the village have come up, there is active support from villagers. To me, the energy I spoke of feeling in the village is more than just about being clean, it is an energy of support and activism within the community. It seems that CRHP’s goals of building empowerment from inside the community have indeed been achieved.

Blog #7: Monday at CRHP in Jamkhed

**Warning: This is very long and divided by day. I spent the last week at the NGO Comprehensive Rural Health Project in Jamkhed (4 hours east of Pune). It was INCREDIBLE! Seriously so amazing. I typed up all my notes because I think they’re interesting so feel free to peruse… also here is the organization’s website http://jamkhed.org/ 

Monday March 25, 2019

Major Events: Lectures on CRHP Jamkhed, Primary Health Care Principles, the Jamkhed Model

1.     Overview Lecture on CRHP Jamkhed

        Drs. Raj and Mabelle Arole founded the Comprehensive Rural Health Project in Jamkhed in 1970. Dr. Raj grew up in the state of Maharashtra and experienced the epidemics of plague and cholera as he was growing up. The deaths of close friends and family affected him so greatly that he decided he would become a doctor to serve his community. Raj went to medical school where he met Mabelle. The two shared visions of serving their communities and were married in 1959. They worked in rural areas and learned about the needs of rural communities. When working at a hospital the presiding doctor decided that the two of them should take over running the hospital. These two young doctors were surprised at this opportunity but took on the work. After working at the hospital a few years, the two went to Johns Hopkins to train in public health, reconstructive surgery, and leprosy. Upon returning to India, the couple was driving home when they stopped to see a friend who was a freedom fighter. When they got to talking about the dreams of the Drs. to provide care to rural communities in need, their friend said to them, why don’t you just stay here? Thus, the idea for CRHP began and stayed in Jamkhed, Maharashtra.

2.     Lecture on Primary Health Care Principles

        There are four principles of primary healthcare which CRHP follows: equity, integration, empowerment, and appropriate technology. To begin with, we defined equity versus equality. Equality is when you treat everyone the same, or give everyone the same amount of resources. Equity, however, means that instead of giving everyone the same treatment or amount of something, you give the appropriate amount to become equal no matter where they started.

        The needs of the most in need must be addressed first, and those in need must be involved and participate and the discussions addressing their needs.

        The second principle of CRHP’s primary health care principles is integration. Their definition of integration is a holistic approach to health, as matches the WHO definition of health (“a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmary”). For example, the CRHP has a mobile health team which functions as a direct health outreach team, and there is a CRHP hospital, but there are also programs for social well being such as women’s, men’s, adolescent girls and adolescent boys’ groups, there is a CRHP organic farm, and there are training programs for village health workers.

        In addition to a holistic approach to health, CRHP itself functions as an interdisciplinary organization. The organization has a team approach to all decision-making and programs and many workers are trained and qualified for multiple jobs at CRHP. It is common for people to have multiple jobs at CRHP in the time they work there. For example, Meena, the preschool teacher, used to be a lab technician, and then when the preschool was created she became the head teacher.

        The programs at CRHP are comprehensive, they respond to the demands and needs of the community instead of imposing policies or practices. The health systems must be affordable, appropriate, and incorporate traditional practices. As an NGO, CRHP wants to cut costs anywhere possible. One of their programs is Jaipur Foot, which provides prosthetic feet to villagers. The cost of the prosthetic, as with hospital services, is on a sliding scale. Patients are asked to pay what they are able. Sometimes that is full price and sometimes that is 100 rupees. The Jaipur foot used to be made out of rubber, but it was realized that these rubber feet did not last long when men especially were working daily in fields. Thus, the foot was switched to wood. The switch from rubber to wood may seem counter progressive, but in fact the use of wood is the most durable and appropriate material for the setting. In addition to this switch, all the pieces of the prosthetic are separate so if it breaks, you are able to replace only one piece instead of the entire prosthetic.

        The final way CRHP attempts to have an integrative approach to health is through multi-sectorial work. The organization works closely with the Indian government. They do not ever want to imply that they are a better resource than the government, they only want to fill gaps. For example, up until ten years ago the CRHP hospital was incredibly busy. It was the only affordable and safe hospital in the area. Then, the government began building more primary and secondary care hospitals. Now, the CRHP hospital only has one full time doctor and one full time nurse on duty. CRHP encourages citizens to use the government resources because ideally you are indeed able to depend on the government to provide certain services.

        The third principle of CRHP’s approach to health is empowerment. First you must come to know the community, listen to them, learn from them, build rapport, and then you may develop a relationship and partnership. CRHP believes in value-based development. The values in health and development must exist within the community in order for change to occur and be sustained. We defined a state of empowerment as a state of identifying yourself, your strengths, being able to make decisions for yourself, to know you have freedom, and to enjoy this freedom. “Success always lies within the community,” Dr. Mabelle Arole said.

        This idea of empowerment explains how CRHP approaches communities with a value-based approach. CRHP will send a mobile health team into communities to conduct basic services, but this tends to be the extent of their involvement, until the community approaches the mobile health team (MHT) or CRHP and requests more involvement. The community members will then meet with CRHP and discuss the strengths of the community, weaknesses, opportunities, and external traits or factors that play a role in the community. After this analysis of the community, CRHP will decide if the community is at need, what needs can be met, and if they should get involved. It is at this point that the community will officially become a “project village,” i.e. one that CRHP is working in. The village is expected to appoint a woman to become the village health worker who will be trained by CRHP and function as the community’s first connection to health knowledge, prevention, and services. The model relies on the trust that the community will value these changes and become empowered to continue them.

        The final principle of CRHP’s approach to healthcare is appropriate technology. Who are the available people to work, what facilities are available, what supplies and equipment are available, affordable, and make sense? Which drugs are essential to have, when can traditional medicines be used? Can energy sources be renewable? Does the education CRHP is providing make sense in context? For example there is a science lab, which young people can participate in science courses at. The science experiments are in biology, chemistry, physics, and computer science. The experiments students will perform teach science to be relevant and applicable to students’ every day lives. The final aspect of appropriate technology is the use of locally available resources: materials and also people.

3.     Lecture on the Jamkhed Model

The CRHP model at Jamkhed has three primary components, the village health workers (VHW), mobile health team (MHT), and CRHP secondary hospital. They work on the same plane:

        The VHW actually inspired the gov’t model’s ASHA role. The village health worker is a married woman with at least one child who is chosen by her community to be trained and serve as the VHW. There is one VHW per 500-1000 population. The village health worker discusses and educates community members about health, primarily with a preventative focus. She discusses social issues such as gender roles and dowry. She screens people and educates about mental health issues such as depression and anxiety. She leads community groups such as the women’s group, men’s group, adolescent girls’ and adolescent boys’ groups. The VHW is not paid, but during her training she receives 200 rupees per training attended, travel, and food at the courses. In the past sometimes VHWs were also given grains, oils, or even saris when they came to training. These are the most tangible incentives for VHWs, but the biggest incentive is the knowledge and skills that come from training as a village health worker. Many of the women we met who were VHWs were from poor, low caste families in which they were not treated as valuable by their families or communities. When coming to CRHP to be trained, for many women it was the first time they had sat or shared meals with women of other castes, and it was the first time they felt they could acquire valuable knowledge. The skills and knowledge they had then gave them a new level of respect in their communities. In addition to this respect, our lecturer Jayesh Ji said that a huge motivation to become a village health worker is the idea and role of helping your own village. For many women this is the most satisfying aspect, to be doing good and valuable work. Once a woman becomes a village health worker she will hold the role as long as she likes.

        The Mobile Health Team (MHT) used to be comprised of a doctor, nurse, lab technician, pharmacist, social worker, and civil engineer. As rates of disease have gone down and development has increased it is no longer necessary to have so many members, so the MHT today is mostly comprised of social workers. The MHT trains village health workers, organizes community groups (partnered with VHW), trains international groups that visit CRHP (about the model), and leads the adolescent groups. They are responsible for integrating programs and the community.

        We then had the opportunity to talk with the three members of the mobile health team, Surekha, Madhu, and Amol. Surekha leads the girls’ group and womens’ groups. She screens for high risk pregnancies, and works alongside village health workers to counsel and ensure the health of villagers. One interesting tidbit was she taught women (and men) how the sex of a baby is decided (one chromosome from XX and one from XY). She shows the diagram and how the birth of a male child depends on the Y being passed from the father. In this way science can be used to remove stigma and violence against women when they give birth to female children. There is still serious gender discrimination in many areas in which women face abuse when they do not give birth to male children. The adolescent girls program is for girls ages 11-18. The program will have up to thirty girls from two villages (the villages must request CRHP to have an adolescent girls program) and meets every Sunday for six months. Girls learn about their bodies, changes they will experience during puberty, and the group also functions as a safe space to discuss gender discrimination and encourage young women to be independent. Surekha said about her work and the work of the MHT and VHWs, “It’s not important how many years you give, it’s important how you give.”

        Madhu is a member of the MHT who had an interesting start to working for CRHP. He was always involved in the Young Farmer’s Club, which partners with CRHP, to learn and educate about farming practices and act as a farmer’s support group. Then one day in his village a mango truck crashed and all the mangos fell out. He helped organize villagers to clean up the mangoes as a CRHP van was driving by. The van pulled over to see what had happened, and during this time they told Madhu he should come work for them! Since then, Madhu has organized many young farmer’s clubs (YFC) in various villages. He used to help VHWs fill out forms and weigh babies because he can read and write. He leads programs on watershed development, organic farming, diabetes, and has led creative education efforts such as puppet shows and plays. He also leads the young boy’s group along with Amol, the third mobile health team member. Madhu said that since working for CRHP he has discovered his faith in humanity. “I find God in all human beings.”

Reflection:        The CRHP has a unique approach to health in that they first go to the community and ask what the community needs. I looked up CRHP online and their website explains the mission as follows: “Drs. Raj and Mabelle Arole want to bring healthcare to the poorest of the poor, CRHP has become an organization that empowers people and communities to eliminate injustices through integrated efforts in health and development. CRHP works by mobilizing and building the capacity of communities to achieve access to comprehensive development and freedom from stigma, poverty, and disease.” The doctors believe that trust builds trust, thus they placed a great deal of trust in the communities they served that the communities had, and have, the capacity to achieve health and overall wellness.       I found this day to be a good introduction to CRHP and all their roles. It is incredible to me how many facets of CRHP exist. They are indeed more than just health, they are committed to the overall wellness of the community. I was especially interested in how the communities have to come together to decide that they want from CRHP. This concept especially helps create a sustainable cycle in the community of addressing new needs. The community recognizes their strengths and ability to find change in themselves, and ultimately creates an environment of empowerment and action!

Journal #3: Thailand

Sawadika! I have just returned from a weeklong excursion to Thailand. The goal of the trip was to learn about the Thai health system, which we did, but it honestly felt like a vacation. I am sitting now in my bed in Delhi in a bit of a cranky mood. It felt incredible to have freedoms in Thailand that we do not have here. We could stay out late, eat whatever we wanted from the street (I still got food poisoning), it just felt liberating! To go on a bit of a tangent, today I was doing my Hindi homework, excited to reward myself with an oreo. I bought a pack of oreos about two weeks ago and hadn’t opened them yet, saving them for a special occasion. I finished my Hindi work and came into my room for my oreo. I checked the nightstand where I had the packet, no oreos in sight, assumed someone cleaning had moved them, but I could not find the oreos! I wasn’t worried and assumed I had hidden them in some other bag, but then, under the night stand, I found the crumpled up wrapper! With a pile of crumbs! I know this is small and stupid but I am so upset. It will probably be funny tomorrow when I go buy myself a new pack of oreos, but tonight it feels like a tangible reminder of the privacy I lack and the little things that are uncomfortable. I cannot stop wondering who came into my room, saw the unopened oreos on my nightstand, decided to open and eat all of them, and not throw away the evidence!!! AH! So it is going to take a few days to readjust to being back after feeling very independent and liberated in Bangkok.

        With this heavy weight off my chest, I can now say that Bangkok is very cool. There are interesting juxtapositions of the high-speed concrete air rail and temples, skyscrapers and street markets. I love the look of the sky rail. Imagine heavy concrete slabs cutting through the air. It is honestly kind of ugly but there is something about the way it asserts itself there, in the thin air, overlapping and casting shadows through the city that I find powerful and beautiful. I am reminded of projections of the future, visions of people travelling in vehicles in the air. It seems to me this vision of the future in a more industrial way exists. 

        On Tuesday I went to the marble temple. I am not sure if it is the marble temple of Bangkok but it was indeed all made of marble. Upon entering the temple one feels a sense of serenity, possibly the cooling effect of the marble, or the aura of power that simply the construction of the structure demanded, but it was a grounding experience to be in this temple. I wish I knew more about Buddhism. I asked Henry to tell me some facts about Buddhism and he told me the following:

1)    All life entails suffering, “unsatisfactoriness,” even when you’re happy it’s temporary

2)    Suffering is rooted in desire––humans attach themselves to desire and worldly things, thus misconstrue the nature of reality

3)    Cessation of desire is possible through the eight-fold path, which includes right thoughts, speech, livelihood, and a few others. Thanks Henry.

        It is definitely interesting to consider some of these ideas when in an elaborate marble temple, but the beauty of the temple did demand a presence of me. The courtyard was lined with cup shaped wind chimes that played various pitches as the breeze came by, creating a soothing jangle and energy in the space. Around the perimeter were various Buddha statues from different regions and in different poses. My favorite Buddha form was the slightly chubby one with a distinct waist and sloping love handles, standing with his right hand extended. This pose is to stop family members from fighting.

        The ideologies of Buddhism were strong in my visit. We were sponsored by Mahidol University, met every day with kindness, top doctors and healthcare professionals, and extravagant lunches. I was slightly in awe of the generosity of our speakers for their time to tell us, moderately scraggly college students, about Thailand’s healthcare system. My favorite excursion was to a rural health promoting hospital/district center. The staff gave us mango and sticky rice to snack on while we toured the center and learned about what they do. The coolest thing is that volunteers support a major portion of the center. Local people, generally elderly with more time on their hands, volunteer and are trained to promote health and wellness in their areas. They will go into villages to check in on the sick, bring medications, encourage people to go to the center, etc. In India, the sub-centers also had volunteers, ASHAs, but the ASHAs were elected, always women, they are compensated for delivering medications and such, and there were only a few per center. At the center we visited, there were tons of volunteers (even a waiting list of, men and women, who only receive a travel stipend to volunteer. They said that being a volunteer gives them something to do as they get older, but also provides a way to actively give back to the community. This was very moving to me because most of the on the ground work is done by these volunteers and the system is sustainable solely on peoples’ values of volunteerism.

        My favorite day in Thailand we went to a community center (that seemed more oriented towards tourists? It was unclear) where we got to bike ride and tie-dye! I was beyond happy to go for a bike ride. I would say that in the last year I have taken to biking more as a method of clearing my head and taking time to myself. To be on a bike provides that incredible feeling of mobility, quickness, but not too fast! I am able to feel myself moving forward, take in the things I pass, let them go. The speed of travel via bike is perfectly manageable. I like this. Also, rural Thailand, wow! Imagine pink, purple, yellow flowers on the trees. Greenery everywhere. There were paths unlike anything I’ve ever seen, concrete, only about six feet wide, elevated over the rivers and fields, interconnected in all of the countryside. They felt like a big puzzle. I want to know who decided to build them.

        In the evening after the bike ride I went out for a fancy dinner at Bangkok restaurant, The Local, with some girls from my program. I hadn’t been feeling particularly connected to anyone in my program so this night felt pivotal. I finally felt like I belonged and had people I could be myself with. Let’s talk about the food, though. Wow. The Local is Michelin “recognized” whatever that means, maybe it had a star, but ooh wee this was Thai food I will not forget. I ordered a fried fish because I thought it would be fun to look the fish in the eyes while I ate it. It was indeed good and fun. The star of the evening was one of the girl’s red curry rib roast. When I took a bite of this dish I had to close my eyes and sit back in my chair. I might have teared up. I have never tasted something so tender and perfectly rich. Truly an incredible experience, if you ever go to Bangkok I recommend going to The Local.

        On the walk back to our hotel we passed Bangkok’s red light district, so we figured we would walk through. It was very interesting because there were definitely some touristy people there who were also checking it out, but there were also people definitely on the hunt for an experience. We went into one of the clubs and made some men very uncomfortable. The waitress started screaming at us because she knew we weren’t going to buy any drinks and one man definitely got shaken up by seeing a group of young girls catching him in the act, if you will. Sex work in Thailand is super prevalent. When you go out after sunset there are women standing outside most hotels and massage shops with women in short skirts beckon people in. I will be honest, I was a bit taken aback by all this. It’s really interesting because I was trying to figure out how I felt and couldn’t really. I hold the opinion that if someone is choosing to be a sex worker then that is their business and it’s just another way to make money. For many people it is very empowering to be in charge of your sexuality and finances so palpably. I did find myself wondering though in Bangkok since the sheer number of women was so high if it’s the same. I would love to hear your opinion. I was talking to my friend about it and she told me that I am being too sensitive. I don’t want to misquote her, but she took a class on sex work and learned that most women who are sex workers see it simply as a job. Some people like their job and some don’t. Like I said though, I found myself struggling with the fact that so many women were clearly looking for work. There were multiple massage parlors per block, each with around ten women on the porch consistently throughout the night. Women standing outside hotels, too, seemed to be waiting for work until late in the evening. One night I went to out with people in my program and a woman I saw on the way to the club around 10pm was standing in the same spot at 1am. I kept thinking about economics, supply and demand. The supply of workers seemed very high, and I am assuming there is a constant demand, so if many women are looking for work, then it isn’t possible that they are getting the best profits or having the most control over the prices. Maybe this is a strange and limited way to look at it, but it made me wonder. I have nothing but respect for all the women I saw and met. I hope for the best for them.

        I was definitely pretty grossed out by all the men I saw though. Maybe this is conflicting with me wanting sex workers to have good work, because they need the clients, but some of these clients were definitely slimy. There would be groups of older men together who would go up to women and touch them and look them up and down, a lot of men would kind of yank women around or hold them really tightly when walking on the streets at night. This made me really concerned and have some questions about the state of empowerment in certain sex work situations in Thailand. But who am I to say… I would love to know peoples’ thoughts and knowledge. Send me an email!

        The next day was our final day of classes in Thailand. Two other students and myself were in charge of leading a “synthesis” discussion of all the material we had covered for the week. I am so proud of how this discussion went. I wanted to pose questions that would spark conversations deeper than simply reviewing the material and instead directed towards discussions of underlying connections and themes we had learned about. My favorite question was at the end of the discussion. I told the class that I had been noticing all week how there are certain things when discussing health in Thailand that we never discussed once while in India they were huge components of public health. My question was, what did we not talk about this week in Thailand and what does that tell us about the determinants of health here? The answers were things like gender, education, poverty, and nutrition. These topics did not come up once in Thailand, and I think that is so fascinating because it shows they are not at all issues anymore, which in turn tells us a lot about Thailand’s socio-economic development. This sounds simple in my explanation, but phew, you should have seen it in context, it was a killer question. I realized preparing for this discussion session that I really enjoy facilitating dialogues and directing conversations. I am really proud of everyone in my class for being so generous with critical and deeply thought out responses, and hey, maybe part of that is because I asked good questions! This felt really good because I have been working really hard in the last six months or so on being a better listener and my question-asking skills. I think taking my sociology methods class on interviewing and trying to get to the root of topics helped me. I feel more confident in how to phrase questions to get a certain level of depth in response. I think another helpful tool has been playing hot seat, a game in which one person sits in the middle and is asked questions for two minutes. This game taught me the importance of listening to people and actually hearing what they say, as well as being brave and curious in how I ask questions. I am very proud of this discussion and happy that my work is paying off. I would love to know how you continue to work on being a good listener and how you think about asking questions. These are areas I am always hoping to improve in.

        At the end of this day I was very tired and needed some time to myself so I watched Netflix and then found a yoga class! It was very nice and challenging to go into yoga mode. I am proud of myself for taking time for myself and recognizing my needs. After, I went for a walk and bought a coconut to drink. Then I felt recharged to meet up with friends at Art Box, a street market type of space. It was a fun adventure because none of us had cell service in Thailand but they told me they were there. I wandered around for a bit then realized there was live music, and thought to myself, “If these people are my new friends that I am vibing with, they will be watching the live music.” Sure enough, there they were! We had the pleasure of seeing one of Thailand’s up and coming rappers, D Gerrard. I would not call it rap per-se, but maybe a mix of bedroom pop, funk, rap, and indie music. He was amazing. Check out his Spotify. There was no way we couldn’t dance, so I got everyone up and we danced about, then other people joined in! We met this super cool girl and danced with her, then we danced with D Gerrard himself. It’s funny because American people are definitely slightly ridiculous, emotional, and over the top to other cultures. We were having a great time dancing about but some people were looking at us like, “These girls are wild.” It was a great time.

      I unfortunately spent all of Saturday in bed with food poisoning. The pad thai from Art Box was just too good. All in all, Thailand was a very nice trip. I would have loved to see the lying down Buddha statue and the home of an American architect/silk trader who mysteriously disappeared, maybe I will go back some day. This journal entry was a bit rough around the edges. Thank you for your patience and please tell me your thoughts on sex work and question asking/listening!

Blog #6: Thailand Health System Field Report

I spent the last week in Thailand learning about the Thai system of health! The following is my field report on the experience.

Thailand’s cultural values have laid foundation for the country’s healthcare system and provided pillars to maintain systemic support. I was immediately struck by the prevalence of value-based policies in Thailand’s health care structure. Values of the right to health exist in the universal healthcare scheme, multiple levels of care, and unique systems in place that consistently aim to better the health of the Thai people.

        In our first lecture we learned that there are no physical barriers between Thailand and neighboring countries of Malaysia, Laos, Cambodia, and Myanmar. These countries are much poorer than Thailand and lack developed healthcare systems. When a public health incident or natural disaster in one country occurs, these five countries have agreed that they will pool efforts and resources to address the epidemic. Thailand acknowledges that with more financial capacity and resources it might contribute more, but the commitment to the wellbeing of the area is more important than an individualistic and conservative approach. This applies to medical care as well. When individuals migrate to Thailand and seek medical care, they are encouraged to register (which implies to pay taxes) and their medical costs will be very low. Even if the migrants are not registered, however, they will still not be expected to pay the entire cost of the health care services they receive.

        Registered Thai citizens receive all the benefits of Thailand’s Universal Healthcare system. The reform of healthcare to universal coverage was founded in the goal that all people should be able to access and afford healthcare services. The system has three schemes, universal health coverage, social security, and military/civil service medical benefits. These three areas of coverage allow all bases to be covered when serving the healthcare needs of the population. There were other particularly unique characteristics of the system that I found exemplified Thailand’s focus on health as a value-based system. In efforts to increase accessibility and decrease overcrowding of hospitals, specialized clinics were opened exclusively at off-hours. This means that if you cannot take off work to wait at a hospital, you could instead visit a clinic before or after work to receive the care you need. To me, this showed that the healthcare system recognizes patients as people, with schedules and obligations. The creation of clinics open at off hours addresses the larger factors that determine people’s access to care such as the financial burden of taking off work or finding childcare.

        The service delivery system is tiered, starting with sub district level health promoting centers. By name alone, these centers express an interest in the extension of health beyond illness and solution, to prevention and promotion. In efforts to reform the healthcare system to improve use and efficiency, a system is in place in which patients can be referred back down to lower levels of care. In an ideal model, a patient would come first to the sub-district and either be treated or referred up. If a patient is referred up to a higher level such as a district or regional hospital, they receive more care and hopefully will become stable. However, overcrowding is a big issue with public hospitals and universal healthcare, so once a patient is stable and recovering, the hospital will refer them back to a lower level care facility. This referral back down allows the higher care facility to have more space while the patient can heal in a smaller hospital, closer to home. The lower level care facilities are also visited by rotating doctor teams from the higher up levels in order to check in on patients and spread resources.

        These policies show a commitment to healthcare as an efficient and effective system, rooted in a genuine interest in the wellbeing of society. Thailand’s policies come to be not only through the hands of politicians, but through partnership between technocrats, civil servants, intellectuals, and activists. I found this incredibly fascinating because it requires collaboration and participation between people from all different sectors and levels of involvement in policy. This concept seems almost utopian to me, as I cannot imagine the surrender of vested interests for such a commitment to the health of the population. But it is real. In every healthcare facility and each lecture, we learned and saw how the value that all people have the right to health was embodied. The doctors we met with worked unpaid overtime but told us they did it for the patients. Thailand has experienced multiple coups and regime changes but the system of healthcare persists. The value of healthcare is core.

      At the end of our program, the Dean of Public Health of Mahidol University told us that the system is not perfect. Thailand will eventually go bankrupt as non-communicable diseases (diabetes, hypertension, cancer) become more prevalent and if Thai people continue to overuse the system. There are long wait times and not enough doctors to work in the public sector. Despite these problems however, she said that Thai culture emphasizes supporting people. This support ranges from personal to political. Personally, community members perform fundamental roles at health promoting hospitals through their volunteer work. The universal health care scheme is founded in preventing catastrophic health expenditures and accessibility of care so that no person is unable to cope. Politically, the healthcare system operates at a loss and has survived various regimes and conflicts. The support of the healthcare system in Thailand is grounded in the value that everyone has a right to health. It is incredible to have seen how such a strong value-based approach to society can actualize well-being for Thai citizens.

Pictures of the hustle and bustle (in rural areas, Lucknow, and Jaipur)

Journal #2b: How am I & Cultural Adjustment

continued from journal #2a...

OKAY, so, me, here, cultural adjustment. There are a few generalizations about India and cultural adjustment things I am getting used to. The biggest one is driving. I have no qualms in saying that people drive crazy here. I don’t even know what the point of having lines on the roads are because lanes do not exist. “Wedge mentality” is how someone in my program puts it. Where there is space, there will be a car, rickshaw, motorcycle, wedging in to fill it. No-passing zones? Do not exist. If you aren’t always trying to pass someone you are not efficiently driving.  It’s really funny because when we travel as a group all mixed up in 4 or 5 cars, the drivers will continually pass each other the entire way to our destination. We all end up at the destination within minutes of each other, but the whole ride there we race to pass each other, veering around busses and cows to get ahead of each other. And honking! If you aren’t honking you aren’t driving. Also, no one wears seatbelts. Trust me, every car I get into I am looking for that seat belt, but they are nowhere to be found. I think of my mom every time I get in a car and whisper, “I’m sorry.” I think someone said the number one cause of deaths in India is motor accident. Honestly now ending four weeks I am not that phased by driving anymore. I don’t want to get stuck in the Delhi traffic, but otherwise it can be fun to weave around and miraculously not hit anyone J.

        A big thing to adjust to is staring. You are not supposed to make extended eye contact with men but they are allowed to stare at you for supposedly up to 20 seconds? Some stares are extra long because of being white and western looking. This has been really interesting. Men and women actually will stare and I never know if it is because I am wearing the wrong thing or if it’s just because I am unfamiliar looking. It doesn’t bother me too much, but it definitely was a really hard adjustment because I think I associate extended staring with a form of confrontation or aggression? As if I am doing something wrong or am being called out? My natural reaction is to feel insecure or embarrassed, even ashamed for some reason! But then I remind myself that this is one of those cultural differences, staring is just acceptable here in a way that I am not used to, plus it’s more extreme because I look different, and also there’s nothing I can do about it. It is still hard to adjust to, I find myself wishing no one would look at me. I am trying to think about it though as a challenge to feel very confident in myself even when the signals I am getting are causing me to question my entire being!!! It is quite an interesting feeling.

        Another cultural adjustment is getting used to near constant solicitations when walking around. This is not just a white tourist thing, but anyone who looks like they have money is actively solicited to rent a rickshaw or come into a shop. I always think it’s funny because in my mind if I wanted to go into a store I would, and a man outside the store telling me to come into his store would not change my mind, and yet outside of every store someone is saying “Ma’am come look at my scarves, “Come inside let me show you my shoes,” etc. This does not apply to upscale stores, but absolutely markets and most city streets. Same thing with rickshaws, if I wanted to hire a rickshaw I would go up to you and do so. Being asked if I want a rickshaw will not make me want a rickshaw. These are little things that I try to laugh to myself at. It does get hard when you want to walk anywhere because you will undoubtedly be asked to hire many rickshaws or buy many things, but it is also a reminder about perspective in India. I am not sure to what extent the forwardness about buying is purely cultural, but I also bet there are other factors at play. We talked about in class how there are literally so many people in India that you have to fight for your spot. It’s the same thing with driving and wedge mentality; you need to do everything you can to make sure your car keeps moving. I do not know how well rickshaw drivers or shopkeepers do financially, but I am sure there is an element of financial necessity that drives the possibly already existent cultural forwardness towards soliciting potential customers. So, while it is stressful for me to be confronted with constant calls to make purchases, I try to have a bit of perspective that 1) I don’t fully understand the way transactions occur in the first place, and 2) there are economic forces involved that heighten the necessity for these interactions to occur.

        These have been some of the biggest things about adjusting to life in India! There are small things that I am getting used to like eating so much roti (yum with a side of carbs!) but there is nothing negative! I hope that I haven’t painted anything in a negative light, all these things I’m experiencing are indeed overwhelming but I wouldn’t have it any other way. I have found some really beautiful perks of not being a tourist and getting to go a little deeper to get to know some of the people behind these interactions. At the Amberfort in Jaipur, we were solicited to buy touristy things like paintings, books, etc., from vendors. We said no thank you and told them we were students (in hindi, woop woop! Mai chaatraa hü), and our interactions with the vendors completely changed. We got talking about where we come from, the history of the fort, and the neighboring village. It was really incredible because to be honest my mind always kindof shuts off when someone approaches me to sell me something. I think “Turn off, disengage, say no,” because a lot of the times that’s the only way to keep going, but to not do that and to instead look another person in the eyes and talk to them was a really opening experience. It feels weird to write this and probably sounds strange to read, but you really do start to ignore people to function on the street. I turn off and I don’t acknowledge other people, and this is hard, but if you acknowledge every person you will end up with a parade behind you. (Again this connects to what I was saying earlier about the necessity people have financially on transactions to occur). But what I am trying to say is that under this umbrella of judgment and reservation about vendors, I had the privilege of getting to know some. One of the men took us to the edge of the fort and showed us the village below that he had grown up in. He told us that his “people” had lived in this village since the fort existed and always would live in the village. I can’t remember everything he told us about the history of the fort and his family but I remember feeling that I had been let in on a very special perspective into the meaning of the fort to him. It was also really interesting, not to be too academic and analytical, but he said he would never leave the village, and from my perspective I thought, “You are so smart and charismatic, why would you want to stay here and have to be a vendor to tourists,” but I had to remember that this man’s values are totally different than mine! His heritage and family are the most important to him, and wow, isn’t that amazing.

        I don’t know what stage of ethno-centric to ethno-inclusive I am in, and these academic and analytical frameworks worry me, I don’t want to get too caught up in them or to spout out these stories and seem high and mighty that I am doing something the right way or better than anyone else. But I am glad to consider the framework a little bit and to be checking myself in my experiences. First and foremost I am there, engaging and experiencing. I am trying not to have all these discourses in my head. I aspire to be a sponge.

        I think with the idea of culture shock and cultural adjustment my plan is to bear it all on my sleeve. I have tried to be transparent with how I think here as I collect my thoughts, maybe and honestly even hopefully, I will look back on these musings at a later date and laugh at myself. What do I know? I know nothing. Who am I? I am no one. But I am also here, attempting to remain conscious and to listen to everything I can. The man who led our cultural competency session told us that in Chinese, the character for listening is composed of the symbols of the ears, the eyes, you, undivided attention, and the heart. It would be more poetic if this were the Hindi character for listening, buttttt, if we are to do anything, to learn anything, to aspire for anything, may you and I listen with our eyes, ears, undivided attention, and hearts.

Namaste.

Journal #2a: How Am I & Cultural Competency

How am I doing? How am I doing!!? Well! I am doing well? I don’t know! But for all intensive purposes yes, I am doing well. Actually, yes, I am doing well. I am coming close to 4 weeks in India, and I think I am ready to say that I am possibly now doing well. This is not to say that I have been unwell the last 4 weeks, but I think only now am I starting to recognize bits of myself again that had been lost in a blur until now. I definitely knew it would be challenging to up and move to a new country, but I thought those challenges would be more obvious and clear cut as opposed to feeling slightly uncomfortable all the time. Yikes.

        I want to discuss cultural adjustment a little bit. We had an entire lecture on cultural adjustment about two weeks into the term, during which I thought to myself, “This is for close minded people who thought it would be easy to come here. I am open minded and aware, and I am doing amazingly.” And then about three days later culture shock really set in.

        Let us begin with an introduction to cultural adjustment. “Culture” is a collection of norms, values, traditions, behaviors, and worldview that people possess. Culture is the acquired understanding and values through which we know how to behave and interpret human interactions. This understanding is gained through living and absorbing the culture. Our dialogue leader emphasized this point over and over again: you cannot truly learn culture from studies. Culture is “learned by doing.”

        After defining culture, we established that there is no such thing as “Indian culture.” I mentioned this in another blog entry, but just as you cannot say that there is a true “American culture,” you cannot generalize all of India as having one culture. Here is where two more terms are introduced: stereotypes and generalizations. These are not the same. A stereotype is an assumption that all fit under a certain generalization. For example, all Americans like fast food. Instead of using stereotypes to describe culture, it is appropriate to use some generalizations. A generalization would say that many people in a culture will exhibit certain tendencies. An interesting example of this is the idea of being on time. Our program director always says to us that we should be on time because most Americans value being on time. I would say this is a fair generalization. You could also generalize that for many Indians, being on time is not as crucial and time holds different meanings.

        The next idea about understanding culture we discussed was the “Shanti Model for Understanding Culture.” Imagine a tree. The tree has three main parts, the leaves/branches, the trunk, and the roots. This tree represents culture. Bam! Imagine a culture tree in your head, nice and colorful. The leaves are the most visible parts of the tree. They include expressions, behaviors, foods, clothes, etc. Next comes the trunk of the tree. The trunk of the tree represents morality, norms, and values of the culture. Finally are the roots. The roots of the tree are not visible to someone standing and looking at the tree. These roots are where the worldview exists. What you believe to be true, your foundational understanding of life, is at the basis of your tree of culture and often not as obvious to an onlooker. The idea with the metaphor of the tree is that we may be able to look at the leaves and draw conclusions of how the tree expresses itself, but we must dig deeper to understand the values and worldview that are in the trunk of the tree. For me, this visual of the tree is a reminder that the tangible signs of a culture are not a full representation of the culture. We must learn to take time and look closer at the make up of the tree instead of assuming the leaves tell the entire story.

        I was also fascinated by the stages of cultural competency. We looked at a flow chart that started at ethno-centricism and ended at ethno-inclusivity. It was interesting because we were talking about it in terms of us as Americans becoming competent to Indian culture, but learning about the stages made me think of so many Americans who also occupy ethno-centric perspectives about people in our own country. Cultural intelligence is not just for travelling abroad, it is for our every day lives as we interact with people who we mark as different than ourselves. The stages of cultural consciousness are as follows (source: Moral Intelligence):

1.     Denial

You live in relative isolation from other cultures. You stereotype others. You do not want to recognize that other cultures/ways of life exist. You unconsciously attribute less than human status to outsiders.

2.     Polarization

You attach negative evaluations to cultural differences. Your own culture is the standard of correctness and judgment towards others. You feel threatened by other cultures. You want to protect your identity, your privilege.

“This is what’s wrong with these people…”

3.     Minimization

You bury cultural differences but recognize top layer of tree differences (behavior, food, dress). You assume that deep down people all hold the same values. Romanticized perspective, “I loved visiting _____, the people and culture were beautiful. I got along with them and had a great time.”

*I would also say that in my opinion, you could think about color blindness in the USA under this category? Like saying, “I don’t see color, race doesn’t matter, we are all humans.” This is problematic because it fails to recognize the cultural differences, and excuses you from truly empathizing and trying to understand someone else’s experience.

4.     Acceptance

You enjoy recognizing and exploring cultural differences. You accept the possibility of other ways of thinking. You realize your own behaviors and values might be different, but are not the only good way to think.

5.     Adaptation

You can empathize and take in another person’s perspective. You modify your behavior in ways appropriate and to respect other cultures. You shift your cultural frame of reference with a conscious effort.

        I found these stages really interesting because they apply to my experience here in India, but also as I said, they offer a framework to think a little more critically about how we interact with those who are different with us in America too. It doesn’t fit perfectly, but it’s something to think about. We also talked about reshaping the way we react to cultural “incidents” of misunderstanding. The basis of this model is the assumption that others are like us (even though they are not). Then, an incident occurs that sparks this reality, “This person is not like me in X way.” This incident gets interpreted in our minds based on past events, experiences, stories, media, and stereotypes that we have collected about the person the incident occurred with. We experience a negative emotion because the incident caused us to be uncomfortable, our status quo and expectations were disrupted, and then our mind forms a judgment towards the person. This judgment reinforces the negative stereotypes that already existed in our mind, and we react with either aggression (yikes) or withdrawal from interactions with the person (or even what they represent to you). The other party is affected by this reaction (either immediately, or imagine the extension of the other party to the group they represent being affected by your prejudice later), and the cycle continues. How can we break this cycle? Well, when an incident occurs and our mind starts to interpret the event, the first step is to become aware of your reaction. What forces are causing your reaction? Are they based in experience, media, stereotypes, fear, confusion? Revisit your emotional reaction and ask yourself how you are feeling. Once you have checked in, let the emotion subside, and observe the situation as a cultural learner.

        This sounds really simple in the explanation, and probably obvious, but I really liked the reminder that whenever a situation or “incident” occurs that causes me to have a quick, judgment based reaction, I need to identify my feelings and why I am having them. Then I need to let the feelings go to be able to really take in the situation. My experience and my worldview are simply irrelevant when I am trying to truly listen to someone or learn from their perspective.

        I can’t think of any “incident” driven examples, but a kindof broad one is the idea of arranged marriage. We have talked a lot about arranged marriage and how sometimes and for some people it is very harmful and enforces the caste system and gender inequality. We have also talked about how for some people it is dutiful and beautiful. Two of my teachers are married and it was arranged, and the female teacher, Archna Ji, said something along the lines of “How am I supposed to know who is the best for me? My family knows me best and my family can better judge who would be a good match for me.” For some of us, this idea may be upsetting. But I think that as a cultural learner, the next steps would be to ask more about Archna Ji’s experience to really learn and try to understand. The purpose isn’t to come to a conclusion about what is right or wrong, but to understand a way of thinking that is different than your own. This is a big idea I want to take with me forever–– I don’t get to have any opinion on how anyone else should live their life. I will talk about this more later in the context of traditional vs. modern medicine… stay tuned.

        PS. Just to gush a little, Archna Ji and Goutam Ji are a match made in heaven. Archna Ji even told me herself the other day on the train to Jaipur that she is so lucky to have such a good partner, she has many friends who not in fulfilling marriages. This is interesting too because I learned that she is glad she had an arranged marriage and believes in its values but doesn’t think it is for everyone. Nothing is black or white! But anyway they are both the sweetest people in the world. I seriously don’t think I have ever met two people who are as kind, thoughtful, or generous in my life. And they are married!?! It’s crazy to me that two people so good have each other. It’s really inspirational I hope that if I ever get married I will have a relationship where we work together so well, care about each other, but also care about others so much. They kind of blow my mind.

        Take a moment to consider the culture tree, the stages of cultural consciousness, or the incident cycle example. How do you react to cultural differences? What work do you need to do in how you cope with cultural differences? I found myself slightly alarmed to be at various points on the stages of cultural consciousness spectrum (polarization, minimization, etc.) and all about different topics. I encourage you not to feel discouraged or threatened by these thoughts or realizations and instead to explore where your feelings stem from. I am growing with you each day.

To be continued in Part 2…

Blog #5: Visit to Bahraich Village

D-I-E transcription: D-I-E is a tool or system for discerning among facts, interpretation of such facts within specific socio-cultural contexts, and subjective evaluations of such information from passionate and opinionated positions. Correctly used, the D-I-E system can be a useful aid for fieldworkers to organize data, distinguish facts from personal ideas, interpret possible meanings of events and situations, and critically examine the bias implicit in their own reactions. For this assignment, students must choose one significant event, incident or observation from each excursion and transcribe

1. Describe

        I walked into Bahraich village where goats skirted about the cow hooves on an open lot, children played games or sat by the water pump, and two men filled a cart full of bricks to be hauled away. Our group was welcomed into the first home off the lot, into the courtyard of Ashadevi. Ashadevi stood less than five feet tall, thin, with a green and red sari draped around her and over her dark brown hair. As our large group curled into the dirt open area between the outer wall of Ashadevi’s home and the adjacent thatched roof manger, she pulled laundry down from the line, creating room to stand. Archna translated that Ashadevi lives here with her five children and husband, who is a mason. Ashadevi then took me and a few other students for a tour of her home. Outside the front door are two circular spaces to hold pots over wood fire, a cooking space carved from mud. Inside the home was dark. On each wall of the house a square hole of four by four inches allowed light to enter.

        As my eyes adjusted to the darkness, I saw that the walls of the interior of this home were smoothed mud, just like the exterior. Carved into the walls were shelves and a small keyhole cut-out on which a sacred figurine was perched. Half of the twelve by eighteen foot home was filled with huge containers. At least as tall, and three times as wide as me, upon closer look I realized these containers, too, were sculpted from mud. I asked who had made these containers to store grains and lentils, the large indoor oven, and Ashadevi said that she herself had carved them all. Returning outside the house, we went under the manger where a large bed of hay and blankets were set up for the family to sleep. Ashadevi’s smallest child, a little girl of maybe three, held onto her legs as she showed us around. The group remarked at how cute the little girl was, and as we were leaving, Ashadevi said, “Take my babies and give them a good education.”

2. Interpretation

        As I first entered the village it was much as I expected with the animals and thatched houses. I began to recognize that the presence of livestock next to water pumps and children playing suggested standards of sanitation different to my own. In the rural America I know, livestock are kept separate from the spaces people cook and clean because of the diseases, flies, and mess they create. When we met Ashadevi, her small frame caused me to wonder if perhaps she was malnourished as a child. Even her youngest child at two or three years old stood up to her waist. Ashadevi then showed us into her home. The huge carved containers honestly made me feel that I was in a museum­­––I had never seen a real home in which such traditional methods of storage were used, and I had never even taken the time at a museum to consider the realities of people using such methods out in the world, in places I did not know. The containers are extremely large to store grains, lentils, etc. throughout the year. We learned in our lecture on rural life that a family’s crop yield completely determines their wellbeing for the year. Thus it makes sense that storage is such a crucial component of the home.

        Ashadevi carved all of the storage canisters, the oven, and the shelves in the walls herself. This surprised me as I expected manual labor to be the role of the men, as India follows a patriarchal system. Perhaps the role of women in the home demands more in a rural setting. This possibility was supported when Ashadevi said that during the days she works in the field. She is responsible for working and maintaining the home. Her husband works as a mason and likely comes home to dinner each day, while Ashadevi literally maintains the foundations of the home, washes, cooks, takes care of her children, and works in a field. The difference in gender roles we learned about is clear here. It is very important to note that when Ashadevi shared her life and home with us, she took great pride in it all. Her pride to me signified contentment and fulfillment in her day-to-day life, and reminded me of the validity of rural life. As we were leaving, Ashadevi told us to take her children with us and give them a good education. This declaration contradicted my perception of Ashadevi’s fulfillment in her life. Perhaps she is not in fact satisfied with her lifestyle, or perhaps she is but wants different opportunities for her children. It is possible to live a fulfilling life but still recognize the hardships you face and the possibilities of other options.

3. Evaluation

        My expectations of village life did not vary much as I entered the village of Bahraich. Upon meeting Ashadevi and being welcomed into her home, however, I had many emotional reactions. My first thought was, “Wow, I never took the time to consider that people actually live like this. This is very different and a difficult way of life.” My mind was blown to a degree, and then I caught myself and scolded myself for my lack of perspective. I realized I was seeing Ashadevi’s home from my own perspective, in addition to feeling a degree of pity that her conditions were not to the degree of development and comfort that I was used to. I felt slightly horrified at myself for feeling this way and devaluing the lives of these villagers because they were different than mine. With these thoughts I became deeply humbled by being welcomed into Ashadevi’s home. “What right do I have?” I continued to ask myself as she so proudly showed us her home and her life. I was unsettled by group members asking her questions like how many children she had and if any had died, how old she was, and what she made for dinner. It was eerie to have a clump of 18 students holding open notebooks and pens in front of this small woman as she showed us the hay she and her family slept on at night. I felt as if she were a subject we were studying. I am still unsure how I feel about this experience. Part of me wonders if these reactions themselves are flawed. Ashadevi wanted to share her home with us, so does my question of the right I have to see her life intrinsically imply some kind of distance of position between us or that her position is somehow fragile? Where does this affliction of fragility I assign come from? Do I have an intrinsic sense of “better-ness” because of my socialization and perception of a good life, thus deeming Ashadevi’s as one to be treated with more sensitivity? Probably. So then I am left somewhere near the beginning wondering who am I to be here and how should I be engaging in these situations.

        I decided to put these thoughts on the back burner in the moment and completely engage in the present. This felt like the most “right” thing to do. By doing this I was able to focus on listening to Ashadevi’s explanations, stories, and thoughts. I redirected my thoughts to engaging and found myself thinking, “Wait Lydia, the way this woman lives is hers. She owns it and it is a way to live that I simply do not have any understanding of. No way. It’s not okay to feel bad for anyone, that is demeaning. I am here to learn about a way that life happens! Every day, here, in this place. I will open my eyes and my ears.” I adopted this mentality and felt much better about my presence in Ashadevi’s home and the space of the village. I think that this understanding of my place in the village felt the most genuine and the most “right” in my heart.

        As we were leaving, Ashadevi said to us, “Take my babies and give them a good education.” Hearing this statement, words with so much weight, I was completely taken aback. It feels wrong even to unpack my reaction to these words without acknowledging them. Was Ashadevi serious? I do not know. Would someone say these words as a joke? I do not know. Do these words indicate a life experience and perspective that I cannot possibly know or fully understand? Yes. Hearing Ashadevi tell us to take her children was not a joke to me. I have thought about her saying this every day since then, and I find myself even more confused about my place visiting the village. When I first met Ashadevi, I reacted with pity in a way I am embarrassed by and would not like to see anyone with. I find it dehumanizing. I thought through this thinking and felt I had arrived at an answer to accept and open up to a different way of life. But it is not that simple. I was able to walk away from Ashadevi and walk away from the village to go back to my program center where staff and teachers cater to all my needs. I still do not know how I feel about Ashadevi’s words. My immediate reaction is to feel sad. Sad that she is in a position in which she would give up her children for the sake of their betterment, implying that she doesn’t believe they will have as good of chances in their community. But then I wonder if this reaction is limited. Again am I imposing my biased perception? Also, family values are completely different in India so perhaps her request was not as serious or dramatic as I am making it out to be.

        I am still continuing to struggle with my reactions and feelings towards this experience. I aspire to hold a conscientious view that includes critiquing my own internal thoughts and ways of understanding, but I have a sense that I will never be able to completely remove myself from the intrinsic ways I have come to think. Thus I must continue to think reflexively. Completing this exercise made me feel extremely vulnerable and concerned about my habits of thinking, and ultimately I have come to the conclusion that perhaps there is no “right” way to think about this experience. Perhaps I will always have complicated feelings. I do know, however, that I am incredibly grateful and humbled to have been shown such kindness and openness by Ashadevi

Blog #4: Community Ownership Field Report

       **Slightly redundant to Blog #3, I submitted this field report after visiting Bahraich

During our week excursion in Bahraich it became clear to me that a major component and theme of public health is community ownership. The principles of community ownership were explained in greater context through Dr. Chaturvedi’s presentation of his grassroots NGO, DEHAT. DEHAT’s theory of change is that if children are assured their survival, development, protection, and participation in developmental processes, then society will be able to achieve sustainable development. For a goal like this to be achieved, and sustained, as is the goal of any good NGO, community based efforts must be encouraged. The NGO’s role is to first encourage behavioral change. In the case of the DEHAT school we visited, the school was given additional attention and resources, and a child’s parliament was created to encourage children to understand their rights, democratic processes, and to have a say in their education and community. Once behavior begins to change, DEHAT helps the community demand government action for support (in the building of infrastructure or funding, for example). This government support strengthens existing systems and encourages the cycle of community participation to continue.

        The goal of DEHAT is to have the people of the community demand their rights from the government, not to be dependent on the NGO. This provides a long-term solution because if the people of the community know the rights they have and should expect, then they are able to advocate for their rights from the government, thus bringing the rights to realization. It is not effective or appropriate for an outsider to come in and tell the community how it should change. The only way change can occur is if the community feels they have ownership over themselves. This is why the participation of children is so crucial. As children are brought up learning their rights and participating in decisions, they will play major roles in the development of the community. It was obvious how excited the kids at their school were to be involved in the children’s parliament. The prime minister especially spoke up a lot to represent his class and kids would whisper things to him that he would then say in front of the whole group. It is exciting to think how having this position and role in his community could encourage his and other children’s confidence and activism for the rest of their lives.

        The importance of community ownership also became clear at each level of primary health centers. When we first met with the AMN (Auxilary Nurse/Midwife) and ASHAs (Accredited Social Health Activist) at the local sub center, they told us how crucial their relationships to the community are. ASHAs manage their own villages and are elected by the community because they are trusted and well liked by the people they will serve. An ASHA must be outgoing, patient, and fervent enough to enter community members’ homes and look in on their health. The election of ASHAs by their communities establishes trust and community input towards their role, thus creating a spirit of support.

        The community trusts ASHAs, which establishes community ownership, but in addition ASHAs themselves advocate community ownership by their commitment to being activists! I was surprised to learn that being an ASHA is not a salaried job. In fact, ASHAs work half the day and only make money when they successfully administer a vaccination, take a pregnant woman to the hospital, or deliver other medical services. The rest of the job, and arguably the most important parts, of educating and prompting awareness about health in the community, are not explicitly rewarded. When ASHAs have educated community members and successfully encouraged medical action, then they will receive their bonuses, as per above. They work half the day and then must go home to fulfill their duties as wives and mothers. These women are active advocates and by performing these roles claim ownership and commitment to their communities. It was very moving to hear the ASHAs’ responses to why they continue to maintain their roles; one of the women said that becoming an ASHA allowed her to continue to learn even when she has traditional roles to maintain, and her world has been opened while she can help her community. The role of ASHA exemplifies the concept of community ownership and empowerment.

        I was sad to hear that the Traditional Birth Attendant role is being phased out of the primary health system. The AMN said that some women in the village still prefer a home birth, so it seems to me that this position is absolutely necessary and maintains traditional practices, which creates a sense of ownership. The ASHA role is now taking this position’s place, as ASHAs are partially trained as midwives. I felt very overwhelmed and inspired though by the power that I felt from the traditional birth attendant. She learned how to deliver from her sister in law and I can only imagine how much she knows that could be lost in a more clinical training. I am sure though that as ASHAs become more commonplace they will hold similar positions of reverence to traditional birth attendants in their communities, but it seemed a shame to me to end the practices of traditional births.

A sense of community ownership is key in the community perception, support, and realization of healthcare. Community comes first in India, thus NGOs such as DEHAT and primary health providers such as ASHAs work within communities and from a place of trust in their attempts to encourage change. These practices are incredibly important foundations in improving rural citizens’ access to health.

Blog #3: Bahraich NGO Visit, DEHAT

DEHAT is an NGO based out of Bahraich started by Dr. Chaturvedi, an Indian doctor who decided he needed to do more for rural India. The vision of DEHAT is to build a child centered society. The mission is to educate, enable, and empower deprived and underprivileged sections of society to ensure the basic rights of children. Their theory of change is that if children are assured their survival, development, protection, and participation in developmental processes, then society will be able to achieve sustainable development. The goal of DEHAT is to have people demand their rights from the government. Their aim is for the communities they serve to become self-sufficient and find long-term solutions. The belief behind this is that if people know their rights (those they have and should expect), then they will be able to advocate for themselves.

        Community based efforts are key to creating a sense of community ownership. For example, the involvement of children in community decisions gives them more ownership of the community. DEHAT believes children have the right to participate in their community and decisions, so a child’s parliament was created. We met with the kids at their school and it was first of all so cute, the prime minister of the child parliament was maybe 10 years old, but there were all these heads of various departments, like education, health, after school activities, and they each explained to us their role. The students hold elections every other year, run campaigns, and vote. Everyone who runs gets some kind of job, which is also very sweet. They act as advisors to the heads of departments. Then, they have a three-day training about their department and the rights of children under each theme. This was so cool to hear about, it seemed really legit. Once a month these students meet with the community council and have discussions in which they can advocate for policies! So cool! It was also very cool because some of the kids were very shy but would whisper things to the prime minister and then he would speak on their behalf. I think this concept is so cool. I am familiar with student councils back home but they tend to end their jurisdiction at the walls of the school. This children’s parliament seems like such a unique, community oriented creation. To me, it shows that there are really creative and progressive ways to encourage political participation and activism. And yes, DEHAT, children have the right to participate in community decisions!!! I think every system should reframe how it views, interacts with, and treats children. They have a lot to teach us.

        With the work of DEHAT, the community has had village “health day celebrations” to literally celebrate the idea of health, raise awareness, educate, and provide immunizations. There were street theaters that showed pregnancy and birthing scenarios that were open to women, men, and children, with dialogues after. It is important that events come from the mind of the community and fit within the local cultural setting so they will be more successful. The first step of DEHAT’s plan of action does include behavioral change, the adjustment of unhealthy or dangerous practices, but once behavior starts to change, the theory of action is that people will adjust to new practices and demand them. I was slightly confused by this concept but it was clarified that “behavioral change” applies to health goals such as sanitation, education, etc. An example given was that now that DEHAT has taught the community about their right to education (people obviously knew about education but a very small portion of children were enrolled in school, so the “right” to education had not been realized for many children, plus the school was underfunded and lacked resources because of rural location and no advocacy for families to send their kids to school), so then the “behavior change” is more children going to school because of DEHAT’s involvement. Then as more people begin to go to school, they begin to believe in its value and know their rights, and will make demands of the government they previously had not. The school is government funded so unfortunately a lot of the time resources will only be delivered if the people actually go to their representatives and state their demands. This is where the theory comes in to play that now the NGO has initiated a theory of change that will continue to be supported by the community as they now know and demand their rights, creating a sustainable solution.

        The Indian government and system of funding is unfortunately a whole other beast, just as ours is.

Blog #2: How can we meet need?

We spent the last week in Bahraich, Uttar Praddesh. Uttar Pradesh is one of India’s largest states, with a population of 4.2 million people. To the north it borders Nepal and the land consists of forest and farming areas. Bahraich is the 5th poorest district out of India’s 700+ districts and has a literacy rate of 53%. Eighty percent of the population depends on agriculture for their livelihood, with major crops of sugar and bananas. Many people are marginal farmers with less than two acres of land, so men will work part time as farmers and part time in other industries such as construction.

           The concept of land is important to grasp, as land ownership holds multiple meanings. Land is inherited thus has meaning and legacy. Also, land is status. Even if you can’t make money off of your land, it contributes to your status as a family. The government has a new policy to give marginalized farmers 17 rupees a day, as a subsidy or incentive to maintain rural farming practices. This is a suitable temporary solution but there needs to be a long term solution, to encourage and support local industries so people don’t have to move to cities. When a rural farmer moves to a city, as based off our discussion, they tend to lack a skill set that will improve their standing in the city. Even if you are making more money in a city compared to what you make in a rural area, the money will not go as far. We discussed in addition to this that moving to the city eliminates the social capital one has in a rural area. In rural areas there is a tight support system of family and the unspoken support of community that does not exist to the same extent in urban settings. Thus the need for a rural economically sustainable solutions exists. A lot of the times in situations like this, a suggested solution is to “teach a new skill that will help them in some other way,” but this approach fails to recognize that this area has always been involved in farming, it is a livelihood, and so we must respect and support this industry. The government and activists do not want rural farmers to be forced to uproot themselves from their traditions and professions, in addition, they want to uphold the significance and importance of land. Dr. Azim Ji expressed as well that a big city economy is not sustainable so we must encourage industry in rural areas. He mused, why not make a call center in Bahraich instead of Delhi? When people are not farming they could work at the call center.  It would be good for the local economy and good for the company as the labor would be less than in a city. If local people are employed they will spend their money locally and the system supports itself. There is room for many creative solutions.

           Azim Ji himself has contributed to Bahraich’s infrastructure. He used to go back to his home village in Bahraich and surrounding villages to teach families about the importance of sending their children, especially girls. Then, one year, the people of his village said to him, “It’s nice and generous for you to spend your time doing this, but there’s no use sending our kids to school because there aren’t any good schools in this area. Maybe if you made a school we would send our kids there.” Azim Ji was taken aback by these sentiments and slightly dejected, because who was he to make a school? He had no experience at all that would make him suitable to start a school. But the words of his community stayed with him, and in the next two years he began to reach out to his personal and professional connections, discussing the possibility of building a school. Azim Ji used all of his personal savings and borrowed money from friends, and the school was built. Now, the Global School of Learning in Bahraich stands and has been in existence for I think 6 years. The school brought in a principal from outside the area, but all the teachers and staff members are from the Bahraich area. Azim and the board of the school want it to be locally sustained. The idea is that over time the community will be so supportive of this school and the education of their youth that it will pay for itself. They also want the school to be accessible. So, one month’s tuition costs 250 rupees, the minimum wage earned in one day. The founders of the school are making the assumption that even a poor family that earns 250 rupees per day would be willing to put one day’s work towards a month education for one of their children. In addition to this incentive, the tuition is discounted by 25% for all girls. As I explained in my overview to India post (Blog #1), girls are way less literate than boys and are not sent to school. The discount offered by this school is a direct effort to increase the number of girls in Bahraich who attend school. Azim Ji said that he has no more savings but he would not have changed anything for this school to exist. To see the leader of our program truly embodying community activism is incredibly moving. I think he is pretty incredible.

           We stayed at the Global School for our week in Bahraich, and part of our tuition went towards the room and food we had there, so in a way we also have helped contribute to the school. They have a strict no donation policy, though, as the goal is to be locally sustainable. Hopefully more and more students will come to the school so that it can operate not at a loss. I think it would be really cool to raise money for solar panels and some other people in my program agree. If they had solar panels it would completely change the game! So we will see where this idea goes…

           The story of this school reminds me of another story he told us about a school in an urban area that wanted more children who pick garbage and recyclables to come to school. In this area, many kids didn’t attend school because they had to collect a quota of recyclables, for which you get money, in order to contribute to their family’s income. The school decided that all the families who already attended the school would bring their recyclables to school. A room was designated in the school where each day students would bring their recyclables. Then, at the end of the day, students who needed to meet a certain recyclable quota could go to the room and take recyclables. The school recognized that the students who were collecting recyclables to support their families could not be expected to abandon this practice, so they came up with a creative solution that still allowed the children to do their jobs but also come to school.

I was so excited to learn that my teacher has actions behind his words, and to reframe my understanding of rural life and initiatives. There are so many possibilities if we listen!

Blog #1: Where will I go and what will I do with my limited time?

In Fall of 2017 I made an instantaneous decision to switch up my academic goals and start fresh. I dropped a class, decided I would create my own major and study abroad. In retrospect my decision making process is all a blur; I changed direction in less than a month. In this process I decided to create my own major in “Public Health.” I am most interested in community wellness, NGO work, urban systems, urban farming, and who knows what else! I researched other schools’ public health programs, brainstormed my own ideas and intentions, and wrote a proposal to the curriculum committee. I also applied to study abroad. I rather arbitrarily looked at public health oriented programs and discovered SIT, the School for International Training. On the SIT website I found my program: India: Public Health, Gender, and Community Action.

And now here I am, in India, studying public health. So what am I doing here? I am taking the following courses:

· Public Health: Key Determinants, Gender, and Equity

· Health Rights Advocacy in Southeast Asia

· Field Methods & Ethics in Social Sciences and Health

· Beginner’s Hindi

· Independent Research Project (1 month)

The major focuses of study of the program are through comparative analyses. We will study and analyze the determinants of health in India, which are gender, caste, class/poverty, in rural versus urban environments. We will take a one week trip to Thailand to compare their universal healthcare system to India’s free health care system. We will compare preventative health care to the clinical model, infectious disease versus life style issues, and community perceptions of health and access to care. I am most excited currently about our focus on NGOs as catalysts, building awareness, advocacy, and connections for people to health services. If you would like a more comprehensive overview and access to our syllabi check out the website:

https://studyabroad.sit.edu/programs/semester/spring-2019/inh/

My teachers are: Azim Ji (program director and head professor of classes), Archna Ji (head of health and wellness, hindi teacher), Bhavna Ji (head of homestays, hindi teacher), and Goutam Ji (head of travel and logistics, hindi teachers). They are each incredible and wonderful people. Each day they share stories and knowledge, love and kindness with us, and this program would not be the same without them.

So, why India? Honestly, my main thought was that I wanted to go somewhere completely new and out of my comfort zone, and this is a once in a lifetime experience. I also am excited to have more than just a tourist experience here and learn as much as I can about a new culture. In one of our first discussions we were told that culture is “learned by doing.” Culture is an accumulation of norms, values, traditions, behaviors, and worldview, and it is important to say that there is no such thing as “Indian culture,” just as if someone asked me what “American culture” is I would not be able to provide an explanation that represents everyone in America. By living here in India I will acquire understanding and values of some aspects of Indian culture through which I will better be able to behave and interpret interactions, which for me will create a new cultural context. I am excited to commit to this, and obviously committing to learning a new culture is not just for my own personal growth, it is also a commitment to live and behave here in a respectful and receptive way. I will discuss in more detail our discussions of “culture” and cultural awareness and adjustment because they’re really fascinating and so so important!

I would now like to provide some background information on India! India has the 2nd largest population in the world (1.34 billion and growing) but the 7th largest geographical area. 17.5% of the world’s population lives in India, which takes up 2.4% of land. Clearly, there are a lot of people but not a lot of space. Thus, population is the number one issue in India.

Here are some facts we discussed and their connections to health:

· 22 languages spoken with 3,000 dialects

How can health be delivered to people who speak a variety of languages?

· 26 political parties, parliamentary democracy

How can the desires of many groups be met?

· 29 states

· 80% Hindu, 14% Muslim, 2% Sikh, 2% Christian, 1% Buddhist

· 67% of Indians live in rural areas

How close is the nearest health center? Are medical professionals employed in rural areas?

· 82.14% Literacy rate in men, 65.46% literacy rate in women *significantly different in rural areas

How can health be delivered if people cannot read? Direct correlation between good health outcomes and education.

The major social issues are gender discrimination and casteism. India is a patriarchal society so many women do not put their health first, nor do men put women’s’ health first because they are not as important members of society. In addition to this, women often need their husband or family’s approval to take certain medications or go to the hospital. Fewer girls than boys are sent to school because they have roles at home. I will discuss gender discrimination in fuller detail in a separate blog entry, but it is important to establish that this is a major focus of our program.

Caste, in India, is practice based in Hinduism of dividing the population based off of duty, or dharma. The idea was that everyone has a role in the system and some are more important than others. At the top of the caste system are Brahmins, spiritual or religious teachers that were the only caste to read or write. Next come Kshatriya, the military, then Vaishya, the merchants, then Sudra, farmers and servants, then Untouchables, those who must perform the most undesirable jobs. No other caste was allowed to have contact with the untouchable caste. Under British rule, certain aspects of the caste system were improved as lower caste members were given more rights. The caste system was constitutionally abolished in 1950 but caste based discrimination still exists and is a major issue. It is still easy to determine someone’s caste by their job, last name, skin color, and land ownership. Our teachers Archna Ji and Goutam Ji told us that it is very common for people you meet to ask you what caste you are and have a reaction based on their caste. Our program director, Azim Ji said that he is from the wealthiest family in his village and his family is well liked, but he is of the untouchable caste so sometimes when he goes to someone’s home in the village he will not be allowed to go into certain rooms and after he leaves they will clean whatever areas he was in. He said that as I child he always felt confused as to why people followed the traditions of caste even if they got along.

We have not discussed the British occupation of India much so far but I am hoping we will because this is a huge factor in how the country stands today. If anything I will do some more research and report back.