Thursday, November 26, 2009

Reflections on poverty, structural violence, and empowerment

In the past month I have spent quite a bit of time visiting the project villages. More often than not every morning I go out with the Mobile Health Team to meet with the Village Health Worker, to drink chai at her house and eat some of her delicious cooking, to see patients, and to meet with the women's groups and farmer's clubs to support them, offer advice, and give counsel. It's interesting how used I am to seeing very simple homes. Everyone lives in a single room with all of the cooking and sleeping supplies stacked up in a corner. I am no longer blown away by such poverty. I no longer think of their lives as wretched existences, but instead think about what made me believe this in the first place.

I think there is a considerable discourse in our society that discusses the horrendous lives of those who lack the same resources as we do. A paradigmatic example would be the Christian Children's Fund (I think) commercials that has an old white man with a big white beard kneeling next to a half-starved, dark-skinned, bloated-belly young child wearing rags and asking you for money. Only one dollar to give this kid all of the vaccines he needs. Only 10 dollars for food for the week. Only 50 dollars for schooling and supplies, etc.

While I think this is probably a good technique for obtaining funding – the greater the distance between our realities coupled with the increased purchasing power of my money the more likely I am to donate – I think it only captures a part of the reality. It misses the wonder and happiness in these children's lives, and, working within a charity model as opposed to a justice one, it also misses the structural factors for why such poverty continues to co-exist with incredible wealth.

In having actual interactions with these people, in seeing them sing, dance, eat good food, laugh, play, work, pray and live actual lives my understanding is shifting. The people are becoming real and the many joys and beauties in their lives are showing themselves. This process began last time I was in India when I visited a rural village and thought the banyan trees, wheat fields, and rivers to be some of the most beautiful sights of my life and started to wonder what makes these people's lives “so bad.” What is it about poverty that makes it such an important part of people's lives and our societal discourse on justice and morality?

I don't think it's just about material resources. Certainly that is an important part of the story but it's clear to me that it isn't the possessions of materials that automatically makes for a good life. These people can still have good lives, even if they live in one-room concrete and tin homes, cook over wooden fires, and have to spend all day traveling to market to sell their produce. Instead, I think it's about the central role poverty plays in structural violence. In short, structural violence says that diseases, suffering, and human rights violations are not produced randomly or by chance but instead are produced and determined by structures and therefore are distributed more to the lowers of the world. Poverty is the most important structure, though gender, race, education, caste, nationality and others play an important role as well. The point is that poverty doesn't automatically make life difficulty – there are many joys in these people's lives! - but that they are more likely to experience intense and overwhelming hardships and traumas and are less likely to have the resources to overcome them. I can see this in how people here in the villages have close family relations, abundant festivals, and great natural surroundings but not enough money to cover a drought or medical emergency.

I think the importance of this viewpoint of the understanding of poverty is important because how one defines the problem determines what solutions one seeks. This can be as simple as the give a man a fish or teach him to fish story: is the main problem his lack of a fish or his inability to acquire one for himself? I see it in the selective- vs. comprehensive- primary health care debate, as well as, in a different vein, in the psychiatry vs. psychology debate. Here, it relates to the role of structures in poverty. It isn't simply that people don't have resources and so giving them money is what is needed. Instead, it's more systematic, and structural change is required. Without question, economic concerns are central here but the approach should be different. What has been so successful about this project is not that they were able to funnel money into poor villager's lives but that they were able to take donations and make excellent use of them by combining them with people's participation to create a change in their world around them. The poverty of the area was addressed by setting up watershed projects that raised the water table and allowed for irrigation, better crops, and multiple yields. In this way the reality of these poor villagers' susceptibility to drought was reduced. Similarly, the poverty and low status of women is being addressed with self-help groups and micro-credit initiatives that extends credit to otherwise ignored populations so that they can work towards creating a better life for themselves. The main factor here is that this approach to overcoming poverty recognizes that it isn't just about materials but rather about marginalization, insecurity, and patriarchy, and that through empowerment rather than just a transfer of wealth then structural violence can be addressed.

Such are my thoughts on how to interact with the inequality around me.

Friday, November 20, 2009

Pics

Posted some pics of me here on Facebook:
You may have to be facebook friends with me. I hope it works...

Wednesday, November 18, 2009

PHC vs. sPHC and what will I do with my life?

My life in the past couple of weeks has changed radically. The training course that I rarely wrote about is done and I have learned a great deal about this place. Right now my life consists of going to villages with the mobile health team, studying Marathi, and reading about primary health care and mental health. I am figuring out what I will be doing in the next couple of months and right now I am interested in helping to develop a mental health program of some sort. More on that later.

I have also been reflecting a lot on my understanding of health, health work, and this organization. CRHP is quite an important place in the history of international health and provides a very successful and particular view of what one can do and what is possible. In reading about this place and the history of health I am forming my own thoughts on what I can do in my life as a doctor. To explain where I am now let me give you a little bit of history about this place and about international health. It’s really amazing to read about the discussions of health and be sitting in an organization that was key in creating a dream.

Some historical context and the creation of the dream:
In the 1940s during WWII a lot of new antibiotics and other medicines came out that drastically improved doctors' ability to treat diseases. These medicines were not cheap, however, and in the 1950s and 60s many international health NGOs ran into financial difficulties as they were trying to improve the health of their populations. The Christian Medical Council in Geneva, a worldwide collection of many different major health NGOs, decided to examine different health models to see how they could more cheaply and effectively improve health. They came here, to Jamkhed, and were moved by the model and how one could bring health to the poor by not focusing on medicines but instead on poverty, casteism, and patriarchy. Their close connections to the WHO meant that instantly Jamkhed was on the world map, and a major health official visited here and wrote a book, Health by the People, that explored different case studies (including Jamkhed) and argued for the possibility of providing health for all in the world. The book came out in 1975, and in 1978 the countries of the world came together in Alma Ata, Soviet Kazakhstan, to declare their commitment to bring health to all via Primary Health Care by 2000. In other words, the entire world had signed on to a commitment to switching the focus of their health care to improving the health of their rural poor by working on development issues, disseminating health information, decentralizing health work, and battling marginalization and discrimination. This organization played an important role in creating that dream.

The debate:
The next year, in a huge twist of events, the Rockefeller foundation hosted a meeting to discuss what to do. It was felt that these goals were a little bit idealistic and unrealistic. They took some of the ideas and came up with a new program, called selective-PHC (or sPHC) that would take some of the initiatives found in PHC programs around the world and provide the funding for them. These programs were known as GOBI-FFF, for Growth monitoring, Oral rehydration treatment, Breastfeeding, Immunization, Female literacy, Family planning, and Food supplementation. A huge debate was started. PHC people accused sPHC of being a vertical program and not doing enough to change the society, and sPHC people asked the PHC what exactly PHC meant, how to operationalize it, measure it, and fund it.

Two views on disease causation:
A recent article breaks down the debate to different positions about disease causation: either one believes chiefly that diseases are socially and economically sustained and need political solutions or one believes that diseases are a natural reality that requires adequate technological solutions. PHC believes in the former and argues that if people are to be healthy there has to be a revolution in the way people interact with each other. Pointing to examples around the world, from Jamkhed and other similar NGOs to China and Cuba, they say that it is not only possible but the ONLY way to achieve adequate health for all. sPHC takes the latter position and says that while we figure out how to treat each other better there are many different programs, ideas, and medicines that could be extended to the very poor and make a huge difference in their lives right now. In this view they focus on the “natural” reality of diseases coming up and seek to implement GOBI-FFF to create better health.

A further distinction:
I think I could break this down to another distinction: idealism vs. pragmatism. The promoters of PHC at Alma Ata had visited case studies around the world and seen the reality of what is possible when committed doctors, health workers, and health ministers work to battle the social and economic determinants of health. They then asked the entire world, with all of its divisions and entrenched interests, to unite behind PHC and to change social and economic realities for the purpose of health. When it didn’t work out they became very frustrated and blamed self-interested institutions, bloated bureaucracies, and selfishness. sPHC on the other hand, tried to work with the reality that existed in terms of how funding is done and health care delivered to move in the direction of PHC. They worked with the world as it was but tried to make it better. The question is how committed are they to PHC and how much change do they really bring?

My thoughts:
I am fascinated by this debate. I think I understand both positions and feel emotionally connected to both positions, but in different ways. I agree with PHC that the primary cause of disease is economic and social marginalization. Of course anyone, no matter how privileged their lives, can come down with any illness. Recent events close to me have particularly shown this reality. Yet at the same time my experiences abroad have shown me the reality of the vast inequalities in health outcomes across the world and driven deep my comprehension of structural violence: that the diseases and suffering in this world are not produced just randomly or by chance by “natural causes” but instead largely determined by social and economic structures and therefore are distributed in a heavily skewed manner to the lowers of the world. In other words, the reality of microbes invading our body and our bodies breaking down interacts heavily with axes of power such as wealth, class, race, caste, gender, geography, nationality, ethnicity, sexuality, etc. to make it so that the lowers are the most likely to have ill health.
At the same time, I also am in sPHC’s position of believing it incredibly naïve of the PHC people to think that people around the world would change their ways for the sake of health. Why would we treat each other better, work for land reform, focus on the poor, and not discriminate against each other because doing so would give everyone a healthy and productive life?

I have this view when I look at CRHP and the possibility of scaling up PHC for everyone. I know deeply that PHC is possible and successful – I am seeing it and experiencing it everyday. CRHP was able to reduce casteism's and patriarchy’s power and create great health for the population. But they also had two incredibly intelligent, dedicated, self-sacrificing, and self-developed doctors devoted to the cause. How can we expect to scale up such inner development, morality, and virtue?
Other large scale versions of PHC, such as China and Cuba, certainly bettered health, but at what cost? Is ideology the alternative to morality? Does large-scale battling of the social determinants of health require ideological revolution? Considering the bloody history of ideological revolutions and the fall of communism, what is the alternative?

I don’t have any real thoughts on what that might look like. PHC, as a worldwide reality, has not materialized. The WHO keeps on renewing its commitment yet very little changes. People talk about keeping the dream alive, rather than achieving it.

I am similarly unsure about myself. I am actually feeling myself to be more of a pragmatist nowadays. I think earlier I was more idealistic – I would have become angry at the failure of PHC and blamed the powerful and privileged. I now fully recognize myself as one of those powerful and privileged and, feeling personally how difficult life can be for everyone, see how difficult it is to move beyond one’s self-interests to work substantively for principles such as equity, justice, and health for all. I am navigating the balancing of taking care of myself and finding my own happiness with what I feel is a future as a global physician who, if he wants to actually achieve health for all, has to battle the very difficult social and economic determinants of health.

Wednesday, November 11, 2009

Understanding the comprehensive in "Comprehensive Rural Health Project"

I originally thought that my blog would serve as a place to write down very complicated and fully formed thoughts. I have tried on several occasions but have found it to be difficult. My understanding of this place shifts and increases every day, and I find it difficult to explain where I am now without explaining where I was before. So I think it would be better to take you on this journey with me as I go along. To start, here are my thoughts from today:

This morning I traveled with the mobile health team - a group of nurses and social workers that back up the village health worker medically and help organize farmer's clubs, women's groups, and self-help groups - to a village. There we met with the village health worker (VHW) and the women's group. We asked the VHW what she felt were the major reasons the village was so healthy nowadays. She gave a wide variety of answers: her training in safe deliveries, the watershed development programs that increased food production, the sanitation initiatives that cleaned up the village, in general health education, the decrease in dowries here, the increased education of women, the increased delaying of marriage until at least age 18, and the diminishing of casteism. Her answers show the multi-level, multi-sectoral health initiatives of the COMPREHENSIVE health project here.

This has been on my mind in the last few days. A medical anthropologist from Brooklyn College is out here and we have been talking a lot about what has made the place achieve such incredible health such that people here in rural Jamkhed have undergone the epidemiological transition and die of diabetes and cancer, not malnutrition, diarrhea, and infectious diseases. She has brought up the point that we tend to think of good health as something that biomedicine has brought us. Biomedicine, in short, is the system of thought that sees health as the absence of disease and so therefore is focused on treatment and direct disease prevention like vaccines. Some people, however, have pointed out that major improvements in our health and a lessening of disease rates came about before we discovered vaccines, antibiotics, and good treatments. Instead, our good health is tied to improvements in the standard of living: better sanitation, nutrition, and housing. From this perspective, the idea that biomedicine has brought us health is known as the "medical heresy."

It makes sense, though, because caesarians and heart transplants are visible and easy to see. They seem to be what brings us good health. In the beginning, the Aroles (the founders) tried that method but they quickly learned that people just kept on coming back with the same problems. So they expanded their views to be a comprehensive health project.

Therefore, on top of the clinical curative services they offered they also expanded into traditional public health work - sanitation and nutrition - but also into the social determinants of health, or those influences that are socially produced. This is called Social Medicine. For instance, the ratio of men to women in Maharastra is dropping to 850 women for every 1000 men because of sex-selective abortion, female infanticide, and less nutrition and medical care for young girls. Obviously, medical services and public health will have little effect if the low status of women is not addressed head on.

So what does comprehensive mean? It means that this organization has a hospital, a mobile health team with nurses, and trained village health workers (biomedicine); watershed development projects to capture rainfall and increase irrigation, soak pits and sewers for sanitation, and toilets (public health); and women's groups, women's microfinance programs, caste-free nutrition programs, a village health worker who is instilled with anti-caste and feminist values, and dramas to discuss the issues of dowry and baselessness of casteism (social medicine).

How does that shape my time here?
Well, I spend half of my mornings in the hospital on rounds or seeing patients. I have seen cataract surgeries, an amputation of a gangrenous leg, and the breaking and resetting of an arm. I also am learning about safe deliveries, oral rehydration therapy for diarrhea, and chronic disease management.
On other mornings I go out to the village and understand how to build toilets and gain their acceptance, how schemes are organized to build village-wide water projects and sanitation, and the ins and outs of mid-day lunch programs.

And occasionally I get to do what I did this afternoon: spend some time with the village health workers.



The women, all in every hue of sari imaginable, sat tightly together in a circle. Their were many smiles, laughs, and laying together. The group was marked by affection as these people came together to increase the health in their community and produce social change. As many of them said, this is the one place besides their parent's homes (they move to their husband's family after married - often a scary experience) that they are given affection. The way they interacted reminded me of my own experiences in youth groups and the love, support, and affection I felt there. In this space they openly discussed dowry, the (lack of) education of women, the difficulties of convincing their husbands and in-laws to let them come, the freedom found in economic independence, their self-worth, the value of women, and their right to respect. It's a powerful space. Today we have a new generation of VHWs very different from the last. Most of the first batch were illiterate, frightened, and insecure. One even said she considered herself worth less than a rat. Understandable, most of their initial work was in self-development. Now the new generation is educated (literate!) and imbued with an ethic of standing up for themselves and striving for equality. It's quite a different world.

And that is social medicine.

I don't know how the Aroles did it, except I don't think they did this on purpose. They were just dedicated doctors who dealt with the difficulties as they came along. I am the one who is putting their work into the categories of biomedicine, public health, and social medicine. Yet that is my job - to try to understand so that it can be reproduced elsewhere. There are a lot of really wonderful health projects out there in this world but someone thinks this place is so unique that they made sure to set aside $13,000 every year to ensure future doctors like me could have the opportunity to experience this place. I feel very blessed to be this year's Mabelle Arole, and I feel I am coming to understand better what this place is about.

Sunday, October 18, 2009

Why India?

My goal in this, my first blog, is to explain why I am in India, why I knew last year that I wanted nothing else but to be in India this year.

I should start my blog by stating my thoughts on writing about India. In reading other people's blogs and from some Indian-Americans' responses to my earlier emails I have learned that I have to be rather careful when discussing anything about India, especially anything that isn't praising the country. Indians seem to respond with a certain level of understandable anger at being negatively portrayed. I understand that I am a white foreigner who has only been here for a comparatively short time, but much of what I say about Indian society I have put together from conversations with Indians or books. A second and probably more powerful idea is that I am a white foreigner discussing a country that while very proud of its heritage is still navigating its identity as a post-colonial state. Any sort of discussion about the vast number of illiterate, the high infant mortality, the village culture, or the low status of women seems to, in my understanding, make people feel that their people are somehow lower than others, that Indians are a backwards and undeveloped people. In this reading, I might simply be pointing out with amazement their pitiful lives.

I hope not to do that. Far from talking about India as an exception, I think it is a perfect example of what is happening in today's world. In my application to come here I wrote about how no where else do I think there is such a vast discrepancy between the lived realities of one nationality. Mumbai has both the largest slum in Asia and the second most expensive real estate in the world, creating a situation where millions live in tiny tin sheds while the world's most expensive home, a 27 story $3 billion mammoth, towers above. The south is home to an information-technology boom as thousands of high-tech engineers exit top-notch universities and push forward the limits of technology, while hundreds of millions of their fellow countrymen are functionally illiterate. The country boasts world-class medical facilities that attract medical tourists from around the globe yet it is one of the few countries with polio, leprosy still exists in the poorest areas, and high infant and maternal mortality present a pretty dismal picture of overall health care.

In other words, there is a sizeable and growing first world in a country dominated by third world realities. In this way it is the story of our world today without the veil of national identities. With a billion people, the full spectrum of possibilities within humanity is laid bare under the category of "Indian." Instead of created, constructed, and imagined identities leading to false barriers, people in this country have to deal with the immensely difficult and jarring juxtaposition created by the sharp proximity of vast inequalities.

I want to learn more about how people manage these inequalities, how they understand where they came from and what to do with them. I have already learned from this organization one way they have changed the situation locally (through empowerment) but I will write about later. These inequalities, I am coming to believe, are the most serious problem affecting our world nowadays. They are growing daily as globalization continues to increase the distance between the rich and the poor. The picture is becoming more complicated than just rich and poor nations, though, as described above. It seems as if the rich in all nations seem to be converging on similar lives and lifestyles while the poor remain oppressed, excluded, and marginalized. This is creating the interesting situation wherein I feel more at home and comfortable conversing with the Indian elite than with the African-Americans 8 blocks away from my Oak Park home.