Hey all,
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/
I hope you enjoyed reading this blog!
Love,
Edgar
Friday, July 16, 2010
Tuesday, May 25, 2010
Leprosy
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.
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.
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.
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.
Sunday, May 23, 2010
I am perfectly healthy, America
This may come as news to some of you, but I am heading to
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
“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.
I receive an unknowing nod, followed by silence, and then the conversation changes.
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.
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.
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 yet no resources exist for actually, acutely ill people here in India.
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.
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:
PPD TB test: 1 dollar.
Influenza vaccine: 20 dollars
12 lead EKG: 3 dollars
15 minute consult with the doctor: 5 dollars
10 minute consult with the dentist: 3 dollars
Dental x-rays, including a panorama of my teeth: free in the dental college
Hep B/C and Iron tests (5 total): 60 dollars.
Total: 92 dollars.
I have no idea how much it would be in
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!
A day in the Intensive Care Unit in
What a different world.
Sunday, May 9, 2010
The different world of India
I have written a lot about my thoughts on health, but not too much about living in
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.
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
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 several times 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.
Let me show you what such a life looks like. It’s on the same earth but seems a world away.
Farming:
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.
Many families have cows, goats, and chickens that live with them and whose milk, eggs, and meat they consume (pictured).
Market:
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.
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.
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
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.
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.
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!
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!
Cooking:
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?
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.
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!
In the end, being here has shown me what
I hope this pictoral and descriptive tour gave you a better sense of life here in rural
Tuesday, May 4, 2010
Positive health and health promotion: Two ideas that shift my thoughts on health work
Positive health
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.
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.
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:
o Physical well-being: A farmer increasing crop yields in a malnourished population through watershed development.
o Social well-being: Local businesses' improve local economies and prevent migrant work.
o Mental well-being: Communities address chronic alcohol habits and domestic abuse.
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.
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.
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.
Related Thoughts:
Paul Farmer:
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.
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.
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.
Advantages to health as a spectrum, not a binary
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.
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?
Instead, I think it's more useful to see that health and disease producing factors shift people either to the right or the left.
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.
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.
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.
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.
It would be a tall order, but it would certainly be important and useful.
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.
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.
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:o Physical well-being: A farmer increasing crop yields in a malnourished population through watershed development.
o Social well-being: Local businesses' improve local economies and prevent migrant work.
o Mental well-being: Communities address chronic alcohol habits and domestic abuse.
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.
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.
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.
Related Thoughts:
Paul Farmer:
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.
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.
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.
Advantages to health as a spectrum, not a binary
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.
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?
Instead, I think it's more useful to see that health and disease producing factors shift people either to the right or the left.
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.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.
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.
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.
It would be a tall order, but it would certainly be important and useful.
Saturday, May 1, 2010
Training the VHWs as counselors: once again appreciating the importance of being comprehensive
For 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.
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.
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.
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.
It's once again been quite an honor to be here.
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.
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.
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.
It's once again been quite an honor to be here.
Monday, March 8, 2010
My heartbreaking session with the village health workers and its influence on my life
I 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.
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.
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.
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.
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.”
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.
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.
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.
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.
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.
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.
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.
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.
*The names of the village health workers have been changed*
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.
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.
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.
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.”
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.
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.
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.
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.
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.
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.
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.
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.
*The names of the village health workers have been changed*
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