tag:blogger.com,1999:blog-73630995489650204472024-03-05T18:29:45.616-08:00Edgar's Masala-flavored ReflectionsEdgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.comBlogger12125tag:blogger.com,1999:blog-7363099548965020447.post-3637864034474480642010-07-16T21:04:00.001-07:002010-07-16T21:05:29.630-07:00Further PostsHey all,<br />I have finished my time in Jamkhed and am beginning my travels across the Indian subcontinent and through the Middle East. All future posts will be cowritten with my girlfriend and can be found here: http://aliceandedgar.blogspot.com/<br />I hope you enjoyed reading this blog!<br />Love,<br />EdgarEdgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com0tag:blogger.com,1999:blog-7363099548965020447.post-61315607140446393702010-05-25T23:19:00.000-07:002010-05-25T23:29:13.031-07:00Leprosy<p class="MsoNormal"><span lang="EN-US"><embed type="application/x-shockwave-flash" src="http://picasaweb.google.com/s/c/bin/slideshow.swf" width="400" height="267" flashvars="host=picasaweb.google.com&captions=1&noautoplay=1&hl=en_US&feat=flashalbum&RGB=0x000000&feed=http%3A%2F%2Fpicasaweb.google.com%2Fdata%2Ffeed%2Fapi%2Fuser%2FEdgar.Woznica%2Falbumid%2F5469692003062794577%3Fkind%3Dphoto%26alt%3Drss%26authkey%3DGv1sRgCK_r49TnprrPogE" pluginspage="http://www.macromedia.com/go/getflashplayer"></embed></span></p><p class="MsoNormal"><span lang="EN-US">I now know many people with leprosy. It was not a disease that I expected to come across ever in my life, but I am definitely familiar with it now. A woman without hands or feet is always in front of the mess hall, just sitting or occasionally begging. During my village visits I have met several older people who had advanced stages of leprosy before they could access treatment. They lost most of their feet and hands as the nerves in these extremities died and they walked on thorns, burned their hands, or did something else that we would all notice but then, importantly, failed to care for the painless, tissue-killing cuts and infections until slowly they lost parts of their body. Nowadays there is treatment to stop the progression of the illness and so the younger people with the infection only develop other signs (white patches on the skin) before they access medication.</span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Seeing people with leprosy has helped me to understand more about stigmatized illnesses and what science has done by giving us biological explanations for disease transmission. In my sociology class I had studied stigmatization as a negative process of cruelty born out of terror and a fear that something similar may happen to you. This is true of leprosy, AIDS, and homelessness, amongst other conditions. Yet seeing it in action with leprosy, and experiencing how much science, knowledge, and understanding can shift the equation has made me wish we could understand social and economic issues like homelessness much better.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Understandings of leprosy besides science tend to revolve around sin, curses, or some other divine action that works against the person with leprosy. Their solution is then to access a spiritual healer but really the person with the illness is ostracized and turned away because they are dangerous to the community. No one else wants to be contaminated by their presence. It is unfortunately and sadly an understandable reaction. I don’t want to set myself above these people: I feel that I too would have had a hard time being near someone with such a terrifying condition without knowing that I am not at risk of infection and there is a treatment. I can see how people felt they had done something wrong so that they could feel safe in knowing that as long as they do “things right” they won’t fall under such sad circumstances. In accessing such a perspective I have come to regard as saints those who have dedicated their lives in the past centuries to caring for and tending to people with leprosy. They gave of themselves so deeply and profoundly for others.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">We still don’t understand exactly how leprosy is transmitted (we know it’s barely infectious, we have the bacteria, but we don’t have the mode of transmission well understood), but we do have a treatment. With this knowledge the world is changing. This famous, historical illness (Jesus cured people with leprosy) is now on it’s way out. There are only 200,000 cases left and it soon will be eradicated. Faith in one’s safety and in a treatment has lowered the stigma so profoundly that an illness that once sent people to “leper colonies” now gives far less terror and fear and through tough social work can be accepted. There is a village health worker here with leprosy, and despite her illness and its prior stigma she can enter into intimate moments of people’s lives and bring babies into this world, handling the vulnerable infant without anyone being uncomfortable. The world has come far with leprosy. Can we do this again with another stigmatized condition? Greater morality (don’t judge and be tolerant) is certainly important, but how else can we create a better society or physical world to reduce other stigmas? It’s an interesting question, that’s for sure. <o:p></o:p></span></p>Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com1tag:blogger.com,1999:blog-7363099548965020447.post-20717703598651764262010-05-23T00:15:00.000-07:002010-05-23T03:06:13.802-07:00I am perfectly healthy, America<p class="MsoNormal"><span lang="EN-US">This may come as news to some of you, but I am heading to </span><st1:place><span lang="EN-US">Antarctica</span></st1:place><span lang="EN-US"> with my girlfriend for six months in October. We will be measuring plankton levels in the ocean to track global warming. It should be an adventure!</span></p> <p class="MsoNormal"><span lang="EN-US">In order to qualify, I have to prove to the National Science Foundation that I am in perfect health and they do not have to worry about me developing cancer, having a molar erupt, or any other possible medical problem that would necessitate an expensive emergency trip to </span><st1:country-region><st1:place><span lang="EN-US">Chile</span></st1:place></st1:country-region><span lang="EN-US"> for treatment. I understand this precaution, but Indians here do not.</span></p> <p class="MsoNormal"><span lang="EN-US">“I heard you were admitted (in the district hospital) in Ahmednagar. Are you okay?” asks a neighbor when I return home. No, I tell them, I wasn’t admitted. I am absolutely fine. I had to go do blood tests, check my heart, and have dental x-rays to prove that I am absolutely healthy. </span></p> <p class="MsoNormal"><span lang="EN-US">I receive an unknowing nod, followed by silence, and then the conversation changes. </span></p> <p class="MsoNormal"><span lang="EN-US">It’s an odd concept around here to spend a lot of money and take two days off to travel to distant hospitals to prove that I am healthy. Why spend the money? It definitely sounds silly when there are tons of people around here who need tests to figure out why they are sick, not to prove that they are healthy! The cost of my Hepatitis B and C and Iron level blood tests is equal to the costs of an artificial limb. I paid the money (60 bucks), no problem. Yet the man without a leg in the outpatient the other day had to wait for a phone call from a generous donor before he could have his leg.</span></p> <p class="MsoNormal"><span lang="EN-US">It’s definitely odd to pay a lot of money for what can be seen as superfluous tests in a country where so many can’t afford access.</span></p> <p class="MsoNormal"><span lang="EN-US">Which brings me to a firm understanding of an idea of Paul Farmer’s: there is definitely a “differential valuation of human life” at play here. My life is clearly “worth” a lot more than most Indian’s, and so the U.S. government will spend money preemptively to ensure that they don’t send a possibly expensive unhealthy person to Antarctica <span style="mso-spacerun:yes"> </span>yet no resources exist for actually, acutely ill people here in India.</span></p> <p class="MsoNormal"><span lang="EN-US">I understand why – I come from a rich nation and the National Science Foundation has to take care of me while I am there – yet to see the difference so starkly, and to see the confusion on my neighbors’ faces so clearly, gives me much food for thought.</span></p><p class="MsoNormal"><span lang="EN-US"><br /></span></p> <p class="MsoNormal"><span lang="EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><span lang="EN-US">On a different yet related note, the cost of the tests I underwent blow my mind. Before traveling to Ahmednagar I took out $250 from the ATM to hopefully cover the majority of my costs. Little did I understand how cheap Indian medical services are. Here is a list of the costs of everything:</span></p> <p class="MsoNormal"><span lang="EN-US">PPD TB test: 1 dollar.</span></p><p class="MsoNormal"><span lang="EN-US">Influenza vaccine: 20 dollars</span></p> <p class="MsoNormal"><span lang="EN-US">12 lead EKG: 3 dollars</span></p> <p class="MsoNormal"><span lang="EN-US">15 minute consult with the doctor: 5 dollars</span></p> <p class="MsoNormal"><span lang="EN-US">10 minute consult with the dentist: 3 dollars</span></p> <p class="MsoNormal"><span lang="EN-US">Dental x-rays, including a panorama of my teeth: free in the dental college</span></p> <p class="MsoNormal"><span lang="EN-US">Hep B/C and Iron tests (5 total): 60 dollars.</span></p> <p class="MsoNormal"><span lang="EN-US">Total: 92 dollars.</span></p> <p class="MsoNormal"><span lang="EN-US">I have no idea how much it would be in </span><st1:country-region><st1:place><span lang="EN-US">America</span></st1:place></st1:country-region><span lang="EN-US">, but I know it would be at least 10 times more.</span></p> <p class="MsoNormal"><span lang="EN-US">A consult with a doctor in a city: 5 dollars. A consult with Dr. Shobha here in rural Jamkhed: 50 cents for the rich, 20 for the middle class, 10 cents for the poor, and free for the very poor. FIFTY CENTS! Are you kidding me!</span></p> <p class="MsoNormal"><span lang="EN-US">A day in the Intensive Care Unit in </span><st1:country-region><st1:place><span lang="EN-US">America</span></st1:place></st1:country-region><span lang="EN-US"> is estimated to cost $4,000. Here it starts at 3 dollars for the bed and may rise to 10-15 for the care.</span></p> <p class="MsoNormal"><span lang="EN-US">What a different world.</span></p>Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com0tag:blogger.com,1999:blog-7363099548965020447.post-51864761372175020952010-05-09T09:44:00.000-07:002010-05-13T06:17:04.717-07:00The different world of India<div><p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">I have written a lot about my thoughts on health, but not too much about living in </span><st1:country-region><st1:place><span lang="EN-US" style="mso-ansi-language:EN-US">India</span></st1:place></st1:country-region><span lang="EN-US" style="mso-ansi-language:EN-US">. I want to remedy that by discussing what I have learned about rural village life in </span><st1:country-region><st1:place><span lang="EN-US" style="mso-ansi-language:EN-US">India</span></st1:place></st1:country-region><span lang="EN-US" style="mso-ansi-language:EN-US">.</span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">I believe this is an important topic to give you some descriptive and picture-filled insight into because understanding the reality of people’s lives here is incredibly crucial to successful health and development work. Some people, notably many in Liberation Theology, state that you must live like the poor in solidarity with them so as to understand their lives and to work amongst them. While that is an extreme call that not everyone can answer, I believe that it is indeed important to have at least some experience of the lives of the people with whom you work. The Aroles here spent 6 months on 45 rupees (7 dollars) a month back in the ‘70s to understand the context of their work. They found that a bar of soap crucial for proper hygiene cost 2 days wages and one flush of their toilet spent a month’s money in water. Quite a wake up call, certainly.</span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">To begin, I think it’s important to understand the role of the industrial revolution in changing our lives. Through the replacement of inanimate sources of power (water, coal, oil, nuclear) for animate (horses, oxen, human) as well as the systematic search for more efficient machinery to replace human labor we completely altered our economy and lives. In our world of high standards of living, labor is worth far more than capital and substance such that when you buy a coffee the cost is more for the labor than the substance. Here in </span><st1:country-region><st1:place><span lang="EN-US" style="mso-ansi-language:EN-US">India</span></st1:place></st1:country-region><span lang="EN-US" style="mso-ansi-language:EN-US">, when you buy something you are paying mostly for the substance, not for the act of creating it and getting it to market. A cup of chai costs 5 cents. That is the cost of the tea. The person making it makes a few fractions of a cent on that, but if you add it up and sell several dozen or hundred cups then you maybe make a dollar – a good income for the day.</span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">The effect of this is that people can’t really afford to buy manufactured goods as easily as we can, but instead can only buy hand-made goods. The opposite is true for us. Just think of the relative cost of organic vs. processed foods. Here, fresh, organic produce is <i>several times</i> cheaper than anything processed so that everything people buy is home-made and home-grown. You go to the market everyday to buy the food you need, and the farmer comes in to sell his own crops rather than to a supermarket where most everything is processed.</span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Let me show you what such a life looks like. It’s on the same earth but seems a world away.<o:p></o:p></span></p> <p class="MsoNormal"><b>Farming:</b></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">As I said, everything is done by hand or with animate sources of power (oxen, horses). The plowing is done with oxen and the seeding, weeding, and harvesting by hand (pictured). Once this is complete, then they dry and process the sorghum, onions, veggies, and other products themselves before hauling it to market. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Many families have cows, goats, and chickens that live with them and whose milk, eggs, and meat they consume (pictured).<o:p></o:p></span></p></div><div><embed type="application/x-shockwave-flash" src="http://picasaweb.google.com/s/c/bin/slideshow.swf" width="400" height="267" flashvars="host=picasaweb.google.com&captions=1&hl=en_US&feat=flashalbum&RGB=0x000000&feed=http%3A%2F%2Fpicasaweb.google.com%2Fdata%2Ffeed%2Fapi%2Fuser%2FEdgar.Woznica%2Falbumid%2F5469319570657393057%3Fkind%3Dphoto%26alt%3Drss%26authkey%3DGv1sRgCKjMoOyvzqqBjAE" pluginspage="http://www.macromedia.com/go/getflashplayer"></embed></div><div><br /></div><div><b>Market:</b></div><div>The market here is a real place where sellers and sellers come together and exchange goods. It’s not an abstract world of supply and demand curves. It’s incredible to see fruit, cattle, and fish markets in full swing.</div><div> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">After harvesting, the foods are brought to the market using bullock carts or trucks. There is of course, change so that now people use fossil fuels but there are still a good number of very poor people who rely upon bullocks to move around.<span style="mso-spacerun:yes"> </span><o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Once they arrive in market you have to sit there all day and sell your goods, unless of course you sell it to a middle man. Most of the time there are individual sellers selling one product – like tomatoes or eggplant – and nothing else. There are literally hundreds of people selling individual items instead of supermarkets where there are probably 30 full time employees selling to hundreds. The need to employ many people is so key that </span><st1:country-region><st1:place><span lang="EN-US" style="mso-ansi-language:EN-US">India</span></st1:place></st1:country-region><span lang="EN-US" style="mso-ansi-language:EN-US"> bars international department stores like Wal-Mart or JC Penny’s from coming in and unemploying so many smaller businesses.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">One interesting bit is that most everything sells. Much of that produce will never see refrigeration so it has to be sold relatively quickly before it goes bad. The effect is that by the end of the day sellers are willing to cut a deal to make a profit, but unfortunately that means you get lower quality food. The best stuff always goes first.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Finally, we arrive at the huge cattle market. Jamkhed is a market town, meaning that for centuries surrounding villages have come here to sell costly goods like 500 dollar (over a year’s wages) cattle. The venue is huge – probably covering 10 acres – and the number of cattle must be in the thousands. The sale requires a middle man. Both parties sit down with the man and under a small handkerchief negotiate prices with him telling them how much they want and what their limits are. The man then finds a good middle point and both walk away happy.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Some smaller but still notable differences lie in the production of sugarcane juice. To have a bull move in a circle and push the gears that operate two wooden cylinders that crush the sugarcane into juice all day long is cheaper than having a diesel-driven version (5 vs. 7 rupees). It also tastes much better as one is made of wood and the other of greased metal. Every time I come into town I take a minute to watch this because I think it’s incredible!<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">One more is the production of meat. If you want to have meat for dinner, you send someone into town to the butcher to buy it. There is no freezer or packaged meat; everything is purchased fresh and used immediately. It’s incredible. I am convinced one of the reasons why food is so good here, outside of the spices, is its freshness! </span></p><p class="MsoNormal"><span lang="EN-US"><embed type="application/x-shockwave-flash" src="http://picasaweb.google.com/s/c/bin/slideshow.swf" width="400" height="267" flashvars="host=picasaweb.google.com&captions=1&hl=en_US&feat=flashalbum&RGB=0x000000&feed=http%3A%2F%2Fpicasaweb.google.com%2Fdata%2Ffeed%2Fapi%2Fuser%2FEdgar.Woznica%2Falbumid%2F5469692641039270369%3Fkind%3Dphoto%26alt%3Drss%26authkey%3DGv1sRgCNHs4dailarmIQ" pluginspage="http://www.macromedia.com/go/getflashplayer"></embed></span></p> <p class="MsoNormal"><span lang="EN-US"><b>Cooking</b></span><span lang="EN-US" style="mso-ansi-language:EN-US">:<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Finally, we come to cooking. Once again, everything is done by hand. Imagine that you have all the fresh ingredients, unprocessed, and no running water. The first step is to collect water from the well or river, which in CRHP villages is nearby due to the installation of many tube wells, but in much of the developing world is far away. Ridiculous, mindblowing fact: the AVERAGE distance a woman (it’s gendered) walks in the developing world to get water is THREE POINT SEVEN MILES! That’s on average, meaning half do more. What a waste of time! Where do you get water for bathing and cleaning your house?<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">Anyways, you get that water to boil over a small fire. You have to process all the food by hand: sorghum seeds into flour, then dough, and finally bhakar (tortillas); onions and garlic peeled, cut, and mixed with ginger and cilantro, then crushed by mortar and pestle into a chutney; and then chicken defeathered, emptied, and then cut into pieces. Then you add it all into a mix in boiling water and voila! now you have a chicken curry meal. <o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">It’s time consuming work. It helps me to understand how much running water and kitchen and household appliances freed up women’s labor and caused so much social change!<o:p></o:p></span></p><p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US"><br /></span></p><p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US"><embed type="application/x-shockwave-flash" src="http://picasaweb.google.com/s/c/bin/slideshow.swf" width="400" height="267" flashvars="host=picasaweb.google.com&captions=1&hl=en_US&feat=flashalbum&RGB=0x000000&feed=http%3A%2F%2Fpicasaweb.google.com%2Fdata%2Ffeed%2Fapi%2Fuser%2FEdgar.Woznica%2Falbumid%2F5469695591402857777%3Fkind%3Dphoto%26alt%3Drss%26authkey%3DGv1sRgCPuS2c7Pv_CYfQ" pluginspage="http://www.macromedia.com/go/getflashplayer"></embed></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US"><o:p> </o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">In the end, being here has shown me what </span><st1:country-region><st1:place><span lang="EN-US" style="mso-ansi-language:EN-US">America</span></st1:place></st1:country-region><span lang="EN-US" style="mso-ansi-language:EN-US"> was like not too long ago and how our civilization has completely altered how we live through industrialization and machinery. It’s also incredible to know how many hundreds of millions live a totally different life on this earth – growing, buying, and consuming almost all hand-made biomaterial goods. It’s been quite a unique opportunity to spend so much time in the villages, including one unforgettable overnight.<o:p></o:p></span></p> <p class="MsoNormal"><span lang="EN-US" style="mso-ansi-language:EN-US">I hope this pictoral and descriptive tour gave you a better sense of life here in rural </span><st1:country-region><st1:place><span lang="EN-US" style="mso-ansi-language:EN-US">India</span></st1:place></st1:country-region><span lang="EN-US" style="mso-ansi-language:EN-US">.</span></p></div>Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com0tag:blogger.com,1999:blog-7363099548965020447.post-74820064434405545072010-05-04T00:31:00.000-07:002010-05-04T01:53:48.857-07:00Positive health and health promotion: Two ideas that shift my thoughts on health work<span style="font-weight: bold;">Positive health</span><br />A major idea that has reoriented my thoughts about health work has been my growing appreciation and understanding of "positive health". In our typical, biomedicine-based use of the term health is defined negatively as the "absence of disease". To be healthy means to not have an illness and to be sick means to have an illness. It's a binary, you are either one or the other, health or sick. We therefore think of working for good health as found in either disease prevention or disease treatment.<br /><br />The World Health Organization, however, gives health a positive definition and sees it as "full social, mental, and physical well-being". While the extreme position of "full" well-being in those aspects is impossible - we all at any time have some issue or another - it does create a spectrum of health, ranging presumably from death to "full" well-being.<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjncra37xa6t5uzJCFx0nBdulo2WeuAfeg0w418I_SsGVkhIT0OIh4YrP_vH8O3_L9zo1xsQ3mvYdZquqbcuk5fMejIj_dua_Q23LF9XskD2YqlSusA_uxEayCVdPq8o8B0B7gaA6Z6n7hE/s1600/Figure+one.bmp"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 402px; height: 90px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjncra37xa6t5uzJCFx0nBdulo2WeuAfeg0w418I_SsGVkhIT0OIh4YrP_vH8O3_L9zo1xsQ3mvYdZquqbcuk5fMejIj_dua_Q23LF9XskD2YqlSusA_uxEayCVdPq8o8B0B7gaA6Z6n7hE/s320/Figure+one.bmp" alt="" id="BLOGGER_PHOTO_ID_5467321918306035314" border="0" /></a>The advantages to this positively defined vision of health are many. The first and probably most important is that one can more easily understand health work that does not revolve around disease treatment or prevention but instead increases the social, physical or mental well-being of a person or population. Some examples for each include:<br />o Physical well-being: A farmer increasing crop yields in a malnourished population through watershed development.<br />o Social well-being: Local businesses' improve local economies and prevent migrant work.<br />o Mental well-being: Communities address chronic alcohol habits and domestic abuse.<br />I would define such work as "health promotion". Instead of disease treatment or disease prevention - the classical realms of medicine and public health - health promotion works on increasing a person or population's well-being and shifts them to the right on the scale.<br /><br />Such a reconceptualization of health and health work is important for creating better health for people in the developing world. It has been stated many times that the major reason for the health advances in the West are not due to increases in medicines or treatments but instead in medical knowledge about hygiene and a general increase in the standard of living. These advances had the effect of creating a healthier environment for us: sanitation, clean water, adequate nutrition, decent living spaces, protection from insects, etc. The evidence for this argument largely draws from the observation that increased life expectancy and decreased disease levels in the West largely preceded medical advancements.<br /><br />Yet when we think about health work or health ministries in the developing world most people tend to stay focused on a doctor-centered, disease-treatment approach. I think that seeing health through a positive definition of well-being rather than the negative of disease-absence allows one to see more clearly the importance of sanitation, clean water, adequate nutrition/crops, better social relations, less "isms" (racism, casteism), greater gender equality, and increased incomes. They aren't "peripheral" or "distal" factors related to health because you don't have to make the longer, conceptually more difficult connection of these to disease prevention. Instead, one can easily see how they relate directly to health promotion and better well-being and health.<br /><br /><span style="font-weight: bold;">Related Thoughts: <span style="font-style: italic;"></span></span><br /><span style="font-weight: bold;">Paul Farmer:</span><br /><br />One interesting debate I have been having while here is how Paul Farmer's work interacts with Primary Health Care (PHC) and health promotion. I feel that Farmer and PHC share a common analysis of disease etiology: it is more related to social factors and structural violence than biological factors. I think they both see illness as a result of poverty, gender inequality, racism, and other factors rather than merely an unfortunate biological event. Yet they differ in what they do in response.<br /><br />Paul Farmer makes a very powerful argument for making sure that people have access to medical care. He does, certainly, write constantly about lack of housing and adequate nutrition as important factors in disease creation but he doesn't seem to advocate wholesale programs for development but rather housing and food as a part of disease treatment. He is the one who writes on the prescription pad next to the medicines, "housing" and "money" as necessities for this patient's health but I don't see systematic efforts to work on these factors in a population. Instead, he seems to stay focused on ensuring that populations have access to quality and efficacious medical care, most famously DOTS for TB and anti-retrovirals for AIDS.<br /><br />I didn't think I would ever say this but I kind of wonder if I prefer PHC to Farmer's technique. To be fair, he seems to be responding to epidemics in many places (Lima, Siberia, Rwanda) but he does also set up general health centers in Haiti and Rwanda. I would like to know more about what happens at these before I say anything with certainty as I have never been there, but he hasn't written about general development work (sanitation, clean water, housing, watershed development) to my knowledge.<br /><br /><span style="font-weight: bold;">Advantages to health as a spectrum, not a binary</span><br /><br />One other important implication created by switching health from "the absence of disease" and a binary to "full social, mental, and physical well-being" and a spectrum is found in how you can work with the spectrum. I find it more conceptually satisfactory when it comes to some situations that become hazy in the diseased/no disease binary. For example, someone with depression may have a couple of hard days in a row or a depression episode but feel well for days or even weeks at a time. When they are feeling fine are they still "depressed"? Are they still "ill"? What does it mean to be "ill" but not feel it for days or even weeks at a time? They aren't easily said to be either sick or not sick but instead somewhere in between. In these cases, I think it makes more sense to put the person on a spectrum, wherein depression episodes may shift them left but the more they heal the more they shift to the right.<br /><br />One issue that arises is how the spectrum works. Placing illnesses on the spectrum as if cancer puts you here and diabetes there doesn't work because it stays within a disease-centric model of health. Where do important health and disease producing factors such as exercise, smoking, obesity, family, bullying, etc. fall on the list? Furthermore, such an attempt would miss all of the other factors (economic, social, and mental) that will be influencing how that person experiences that illness: will she have the money for treatment? will she be ostracized and kicked out of the family? does she have the social support and mental capacity to withstand it?<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIAQJJKD59JReE6FmqvRpiLbwA3Ch_Eey1nHhT8BOySEfAUB5uc7PEOmo7gRaIYXwZ1mkjC5tqE3sc8yVp9sEBzppTVzcHxGhK-tKJBWzr5v-4oNKqp_RyqGFtDTjRhTV2OMSZozfFFJ8x/s1600/Figure+two.bmp"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 410px; height: 127px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIAQJJKD59JReE6FmqvRpiLbwA3Ch_Eey1nHhT8BOySEfAUB5uc7PEOmo7gRaIYXwZ1mkjC5tqE3sc8yVp9sEBzppTVzcHxGhK-tKJBWzr5v-4oNKqp_RyqGFtDTjRhTV2OMSZozfFFJ8x/s320/Figure+two.bmp" alt="" id="BLOGGER_PHOTO_ID_5467322563906372866" border="0" /></a>Instead, I think it's more useful to see that health and disease producing factors shift people either to the right or the left.<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqXKY2Pwhq-ZiHpOKhj6UK3r10EzOzz2whNehfzAV5WJQMd_Isg06bTjpfJRI_60G40b3jZ44ybNM5ZcWNfVMfpbZrvFU9bbUL93Ja7sUDebaqmTFU0ZUhF-SSDer03a5AysW-NzkSN38h/s1600/Figure+three.bmp"><img style="margin: 0px auto 10px; display: block; text-align: center; cursor: pointer; width: 384px; height: 173px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqXKY2Pwhq-ZiHpOKhj6UK3r10EzOzz2whNehfzAV5WJQMd_Isg06bTjpfJRI_60G40b3jZ44ybNM5ZcWNfVMfpbZrvFU9bbUL93Ja7sUDebaqmTFU0ZUhF-SSDer03a5AysW-NzkSN38h/s320/Figure+three.bmp" alt="" id="BLOGGER_PHOTO_ID_5467322978419299186" border="0" /></a>In this way one can take into account all of the factors working to create health and disease. One can take into account how war or bullying shift one to the left or how exercise, secure employment, and good social relations can shift one to the right. It works well for understanding how social, economic, and political realities as well as personal decisions impact health.<br />One intriguing activity is to attempt to figure out the magnitude of the shift for each factor in affecting health and well-being. It would be a difficult activity but I think it could be conducted similarly to how the Disability Adjusted Life Years (DALYs) were done and also used to determine where health resources should be done.<br /><br />For those unfamiliar with DALYs, the WHO and top universities collaborated in a series of conferences to determine the relative impact of certain illnesses or infirmities - malaria, AIDS, flu, blindness, paralysis - on a person's health through questions basically saying which would make you worse off, and then took these relative numbers as multipliers and applied them to prevalence to come up with worldwide disease burden, as per my understanding. In effect, they attempted to calculate which illnesses are causing the most trouble today and therefore deserve the most funding and attention.<br /><br />I think a similar process for health- and disease-producing factors would be absolutely fascinating as well as important. Instead of being once again disease-centered like DALYs, this analysis would focus on the relative importance of war, gender inequality, exercise, diet, bullying, poverty, clean water, nutrition supplements, micro-credit schemes, spirituality, community cohesion, etc. After such an analysis one would have a good sense of the most important in general health- and disease-producing factors and could focus funding and attention on these.<br />It would be a tall order, but it would certainly be important and useful.Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com1tag:blogger.com,1999:blog-7363099548965020447.post-21875333323920228732010-05-01T05:42:00.000-07:002010-05-01T05:44:15.780-07:00Training the VHWs as counselors: once again appreciating the importance of being comprehensiveFor the past 5 months I have been weekly training the village health workers (VHWs) about depression, anxiety and counseling. Yesterday I finished a month and half long training on counseling - a project I had begun to hopefully develop the VHWs into counselors able to treat the depression in their village. Throughout this time I wasn't certain what the village health workers' job as counselors would look like because I had never seen barefoot counseling in action and was drawing instead on the models provided in books. These books were written by psychiatrists working within hospitals and seeking to provide the important benefit of counseling to their patients yet not having enough time for the high caseload. The system they designed of training high school educated workers in counseling is indeed useful, but probably not as good as CRHP's approach because it lacks the comprehensiveness to deal with the social and economic factors producing mental illness. It remains within the confines of the hospital. Let me explain.<br /> <br />First of all, the counseling I am describing is not any sort of psychotherapy in which the counselor has a deep understanding of the workings of the human brain and is able to guide the person through the experience to mental health. Instead, barefoot counseling is much simpler: reassuring the person that they are not going crazy and their illness is common; providing an explanation by connecting the illness to some stressful life event' providing relaxation exercises and advice for difficulty sleeping, tiredness, panic attacks, etc.; and engaging in problem-solving by discussing problems in people's lives and seeking solutions to them. The first three are useful to the patient in that they calm the person down, help them to realize where their illness came from, and provide some relief, but they don't require a very sophisticated education: these women have been aware for a long time that the stresses of poverty, gender inequality, and violence create serious problems in people's lives. They may not have expressed it as a mental illness, but they certainly understood the physical and mental effects. Now they have the knowledge set to understand more explicitly the connections between stressful life events and depression and anxiety and impart this knowledge to their fellow villagers. I think this has been the major achievement of the training thus far.<br /><br /> It's the last part - problem-solving - that showed me the problem with the hospital-centered approach. Basically problem-solving is creating a space to discuss problems in people's lives and possible solutions for them. When I introduced the idea I asked how the VHWs do this in the villages and they came forth with a plethora of answers: providing a loan to a family in need of medication, cooking up a community-sponsored wedding feast to relieve the pain of a poor woman's shame at marrying her daughter without food, and bringing an unemployed and lonely woman to the fields with them to work. In effect, the VHWs strike at the roots of the problem while concomitantly providing emotional support.<br /><br /> I feel this is the mental health worker's dream: providing therapeutic treatment (medication and counseling) while also providing community-based emotional, social, and monetary support. One VHW told me while we both interviewed a depressed woman that this woman needs four things: a house, money, a family, and treatment (medication and counseling). Through the VHW model woman can receive help from the Women's Groups and Self-Help Groups to buy a house or start a business as well as receive treatment, and therefore seek mental health through tackling three of her problems. In the hospital-based model, all that the counselor sitting in the clinic can do is provide treatment and help the person to think through how to solve their own problems. To me it's clear that the VHW-, community-centered approach is better. Now I feel I understand why the WHO asked CRHP to write a chapter for its book on promoting mental health around the world: by focusing on social change (reduced casteism and increased status of women) as well as economic upliftment (reducing widespread poverty) while also providing in-village health workers and a central clinic this place went far in promoting mental health and preventing mental illness.<br /><br /> It's once again been quite an honor to be here.Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com2tag:blogger.com,1999:blog-7363099548965020447.post-8881371787492578312010-03-08T00:03:00.000-08:002010-03-08T17:34:19.861-08:00My heartbreaking session with the village health workers and its influence on my lifeI had an especially powerful and moving session with the village health workers the other day that I feel is important to write about. We were discussing anxiety and after some repetition of the meaning and symptom of anxiety about a third of the women recognized it in themselves. It was a powerful hour and a half of life story sharing, crying, and mutual support as we all came to realize the extent and toll of mental ill health in this area. It was especially emotionally jarring for me because many women looked to me for help and I felt powerless to do enough.<br /><br />Before I go on, however, I think it’s important to give some background. I have been teaching these women about mental health for the past two months, covering such important topics as mental illness, mental health (in a positive sense!), depression, and now anxiety. They are soaking in the material because they are absolutely incredible women keenly interested in improving the situations of their fellow villagers. My initial goal is to just raise their mental health literacy so that they are even aware that mental illnesses exist and then to discuss prevention and treatment! There is, of course, plenty of experience with “madness” and people talking to themselves, etc., but no knowledge of where this comes from, no idea that excessive sadness or worrying can also be seen as illness, and no concept of the possibility of treatments. It’s been quite eye-opening to realize that I am introducing many of these women to a world in which these afflictions need not be accepted as a normal part of life but instead treatable and preventable life phenomena.<br /><br />It took some time for them to understand depression. It’s understandably difficult to conceptualize for the first time without any prior life exposure to the idea, and I broke it down to an imbalance of the “juices” in the brain caused by a particularly stressful life experience that causes excessive sadness. It’s tricky work because for people who haven’t grown up with a culture that includes psychology the idea that “excessive sadness” can be an illness is not intuitive or easily accepted. After running through the symptoms, however, and talking about how depression is different than sadness because of its duration, interference with daily life, and physical symptoms, the women began to open their eyes to this new world.<br /><br />With this solid foundation teaching anxiety was much easier. On the second day, however, during the review, the meaning and symptoms of anxiety finally sunk in for many of the women. During the tea break three of them came up to me and shared their stories. The first woman, Soonya, talked about her daughter. The daughter’s husband beats her, causing her to sometimes feel that she is suffocating, to occasionally tremble all over her body, and to feel her heart beating rapidly whenever he comes near her. The second, Jyoti, discussed her own experience earlier in life with suffocation, trembling, dizziness, worrying too much, intense fright, and avoiding certain situations born out of her experience in her husband’s family when she hadn’t yet given birth to a son. The last one, however, was the most powerful.<br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh37fI14c5nxlxlfUYItFUpBAuF0tkzUIcbgnxRe41xxmwuW3LZYzCF2oBKbKBuA1-kgU5R9UgY1_lbzDmFlFt6hXUMPTXgRFOIC4EsdrfX3DHNEgYqSPw8bBXtL3ovmh3-upfLqqv9H4dq/s1600-h/100_1211.jpg"><img style="float:right; margin:0 0 10px 10px;cursor:pointer; cursor:hand;width: 240px; height: 320px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh37fI14c5nxlxlfUYItFUpBAuF0tkzUIcbgnxRe41xxmwuW3LZYzCF2oBKbKBuA1-kgU5R9UgY1_lbzDmFlFt6hXUMPTXgRFOIC4EsdrfX3DHNEgYqSPw8bBXtL3ovmh3-upfLqqv9H4dq/s320/100_1211.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5446171769280124226" /></a><br /> Surya (pictured) is a new village health worker with a gorgeous smile and eager countenance. She quietly told me about her life, looking into my eyes with her soul as she recounted her pain and yet expressed her strength. When her husband is around things are fine, but when he is gone her father-in-law beats her up. She has many of the symptoms – palpitations, suffocation, dizziness, and difficulty sleeping – and others indicating a coexistent depression. It was tough to hear. Then she asked me what to do. Knowing that medication, counseling, and support groups wouldn’t make a difference without the triggering situation of her abusive father-in-law being removed I began to hatch a plan in my mind where she teamed up with the women’s group and accost the man demanding that he stop. At this point, the translator looked at me and laughed a sad laugh. “This is India,” he said, “if she does that, she’ll be thrown out of the house.”<br /><br /> As the translator and I talked it out and realized that nothing could be done, Surya waited patiently for the reply in Marathi. How could I tell her? How could we say that there is a route to a better life, and that the main part of it is something seemingly impossible? How could I tell her she was trapped, and unless she found a way to escape life was only going to get marginally better with medication and counseling? I ended up thanking her for her strength and saying this was a very difficult situation that would require more discussion, and that we should wait for Dr. Shobha. It was a dodge, but I didn’t know what else to say.<br /><br />We returned to class, they shared their stories, and what was supposed to be time to make up skits turned into time to discuss reality. Emboldened by the previous village health workers, woman after woman came up and shared their life histories of abuse, of getting burned for not having enough dowry money, of getting beaten for producing daughters and not sons, and even of getting stabbed by a drunk and angry husband. They shared the symptoms of anxiety they expressed, and we had an all-too-real and unexpected session of “case studies”. When asked, 1/3rd of the women stated they had contemplated committing suicide. <br /><br />It was heart-breaking and unsettling, but for me the most difficult part was their request for help. They all looked to me, and I explained that I am actually not a doctor, that I am just a student and that I teach myself what I teach them. I have promised to look into counseling and support groups so that we can work together to start those programs but the lack of an immediate response or answer saddened me. These things take time, and it will definitely be awhile before they will find the happiness of health again, but I just wish there were systems in place already.<br /><br />The class ended with my repeatedly thanking them profusely for their courage and strength to share their life stories. I talked about the trust and community that had been built today. We then stood in a circle, held hands, and sang their song telling women to leave the kitchen and come together to make a better world. It was powerful. <br /> <br />In the days that followed I spent awhile reflecting on Surya’s position. She is not alone. There are many thousands of women here and around the world who are trapped in such situations. Women have incredibly low value placed upon them here. I believe, from a materialist viewpoint, that this is largely so because of the Indian social practices of patrilinearity and dowry. In India, a poor family loses its hefty investment in raising their daughter when she leaves the house for her husband’s upon marriage. On top of that, each daughter means a burdensome dowry that often puts the family in debt but must be paid if she is to marry. These social practices are incredibly difficult to alter, but it makes me wonder dreamily if only, if only. It would make such a difference.<br /><br />The stories of the women made me appreciate with new insight the good brought by feminism in the West. India has only a budding women’s movement, and it only really reaches the rural areas via development organizations. There is a lot to be done, but people are working on it. Social change takes a long time. We were there earlier, and we ourselves still have a lot further to go.<br /><br /><br />And that change for the better is what I am committing to. People here often ask me what I plan to specialize in or do after medical school, and I tell them that I don’t know. I am keeping my options open. I am, however, certain that I will make it my life’s work to bring more good into this world. And I will no doubt draw some lessons from this place. Jamkhed has a chapter in the WHO’s book on mental health policy in which they discuss how their work for women’s empowerment, the end of casteism, and poverty reduction has affected the social determinants of mental health and produced a healthier society. In this preventative view, by making the villages a better place to live materially and socially they have created physically and mentally healthier populations. In other words, they have created “development”, and they did it by wielding their knowledge of curative care in ways that went way beyond the hospital. I imagine I will do something similar.<br /><br />The next question is whether that will be in mental or physical health. I don’t know. I have read about and sort of understood how mental health is a blind spot in global health. It’s not talked about enough and still stigmatized in our society, let alone not having any knowledge about even the existence of mental illness in many parts of the world! But that weakness was brought home to me in this experience. The mobile health team has been working with some of these women for 30 years and even they didn’t know all of the stories nor understand the anxiety many of these women were experiencing. Jamkhed has made a huge difference in physical health for 40 years, but only recently has mental health become an objective. I understand the need, but we’ll see where I go. Either way, that class was quite a powerful learning experience, and I don’t think I will forget it anytime soon.<br /><br /><br />*The names of the village health workers have been changed*Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com1tag:blogger.com,1999:blog-7363099548965020447.post-79357501988074291222009-11-26T02:33:00.000-08:002009-12-16T06:25:56.231-08:00Reflections on poverty, structural violence, and empowermentIn 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. </p> <p style="margin-bottom: 0in;"> 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.</p> <p style="margin-bottom: 0in;"> 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. </p> <p style="margin-bottom: 0in;"> 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?</p> <p style="margin-bottom: 0in;"> 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.</p> <p style="margin-bottom: 0in;"> 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. </p> <p style="margin-bottom: 0in;"> Such are my thoughts on how to interact with the inequality around me.</p>Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com1tag:blogger.com,1999:blog-7363099548965020447.post-50788133783472652082009-11-20T01:29:00.000-08:002009-11-20T01:38:01.847-08:00Pics<a href="http://www.facebook.com/profile.php?ref=profile&id=1010357#/album.php?aid=2144456&id=1010357">Posted some pics of me here on </a><a href="http://www.facebook.com/profile.php?ref=profile&id=1010357#/album.php?aid=2144456&id=1010357">Facebook:</a><br />You may have to be facebook friends with me. I hope it works...Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com0tag:blogger.com,1999:blog-7363099548965020447.post-30858593245390875272009-11-18T21:05:00.000-08:002009-11-21T04:04:56.325-08:00PHC 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.<br /><br />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.<br /><br /><span style="font-weight: bold;">Some historical context and the creation of the dream:</span><br />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. <br /><br /><span style="font-weight: bold;">The debate:</span><br />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.<br /><br /><span style="font-weight: bold;">Two views on disease causation:</span><br />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.<br /><br /><span style="font-weight: bold;">A further distinction:</span><br />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?<br /><br /><span style="font-weight: bold;">My thoughts:</span><br />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.<br />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?<br /><br />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?<br />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?<br /><br />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.<br /><br />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.Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com1tag:blogger.com,1999:blog-7363099548965020447.post-85422554187350360002009-11-11T03:43:00.000-08:002009-11-11T23:40:42.706-08:00Understanding 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:<br /><br />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. <br /><br />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." <br /><br />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. <br /><br />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.<br /><br />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). <br /><br />How does that shape my time here? <br />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. <br />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.<br /><br />And occasionally I get to do what I did this afternoon: spend some time with the village health workers.<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtU2IEjMwu1GKxE2xmKGP3gj1tybIUy_kWCaye8CNtllsqiiCEoUiy03p9BVc_xDVW2hM88YuddPQVdypMBPYsK4rsrt6dLr-c8Tc1xK9FKko6UhPETZ7z_OC5xp2uDmRuMmKb2uP7LVJ4/s1600-h/100_0838.jpg"><img style="float:right; margin:0 0 10px 10px;cursor:pointer; cursor:hand;width: 320px; height: 240px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtU2IEjMwu1GKxE2xmKGP3gj1tybIUy_kWCaye8CNtllsqiiCEoUiy03p9BVc_xDVW2hM88YuddPQVdypMBPYsK4rsrt6dLr-c8Tc1xK9FKko6UhPETZ7z_OC5xp2uDmRuMmKb2uP7LVJ4/s320/100_0838.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5403118477340303026" /></a><br /><br />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.<br /><br />And that is social medicine.<br /><br />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.Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com0tag:blogger.com,1999:blog-7363099548965020447.post-59700917084851495672009-10-18T05:14:00.000-07:002009-10-31T02:01:21.095-07:00Why 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.<br /><br />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. <br /><br />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. <br /><br />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.<br /><br />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.Edgar in Indiahttp://www.blogger.com/profile/17747596530414552553noreply@blogger.com0