“Namaste. Meera naam Eileen hai.” I introduce myself shyly, aware of my clumsy Hindi, to a group of women sitting in a misshapen circle. We sit on a rug to protect us from the hard concrete floor, in a room plastered with posters of the alphabet, of famous Indian leaders, and of pictures of fruit – the local primary school classroom in Sitla. These women, decorated in bhindis and bangles, all look at me kindly. One holds a large notebook, flowing with Devangari script that record Meeting Minutes– the old-fashioned way of doing so, before people upgraded to computers. One woman nurses her baby. Another passes around the attendance book for people to sign.
Today, I am at a local Village Health and Sanitation Committee (VHSC) Meeting in Sitla, the perfect place and time to capture a snapshot of what rural health is like. Without the abundance of doctors or a rigid public health framework, how do people in areas like Kumaon deal with health? How does the government keep track of health in these areas? The VHSC is your answer. More specifically, the VHSC is a part of the larger framework of the National Rural Health Mission, initiated by the government of India. The purpose of the NRHM is to “improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children.” Their goals include reducing the infant mortality and maternal mortality ratio; increasing access to public health services such as women’s health, child health, water, sanitation & hygiene, immunization, and nutrition; and performing other public health tasks in keeping up with standards set by the World Health Organization (i.e. the Millennium Development Goals). Along with other initiatives and instructions, each village is supposed to have a village health plan prepared by a local team: the Village Health and Sanitation Committee of the Gram Panchayat (village leadership).
As each woman introduces herself and her role, I am overwhelmed by the fact that I am witnessing a very different practice of health care and public health than the one in which I was raised. Here, health promotion is a community effort, where various actors take part and convene together monthly; issues are raised, workers are trained, and the sparsely populated community is connected to the public health system. This health committee is composed of the Pradhan (village leadership); Vice Pradhan; Block Development Officer of Ramgarh block (which is basically a statutory position since he is usually absent); the auxiliary nurse midwife (ANM) who helps run the ANM center and provides antenatal and neonatal care; accredited social health activists (ASHA workers) who act as community health workers in promoting access to health care at the household level; anganwadis who are workers that ensure infant and child health (also government commissioned); “jal karmis” or water workers; elected ward members; and school teachers. Prema-ji, the Chirag health leader, administers the meeting – a task that NGOs like Chirag do in supporting ASHAs and monitoring village health committees.
They start with a recap of last meeting, and then move onto the first item on the agenda: jaundice, a common problem in the area, especially with the quality of the water. “People are not being tested for whether they have jaundice or not, and they are taking the wrong medication for it. It is our role as the Village Health and Sanitation Committee to educate people about taking the appropriate treatment,” one woman exhorts. The others are attentive, some even taking notes.
They quickly move onto the next topic: vaccinations. Prema-ji rolls out her yellow poster, which lists the vaccinations for children, the disease they prevent, when children should receive them, and how children should receive them. This is particularly interesting to me since I am involved in vaccination research at Penn especially in regard to the American vaccination schedule and rising vaccine hesitancy. To compare the two schedules surprises me: here, it is BCG (for TB), DPT (diphtheria, pertussis, tetanus), polio, Hep B, measles, vitamin A, boosters. No MMR, no Hib, no chicken pox, no sign of vaccine refusal or hesitancy. Prema also points to a list of bullet points which show basic precautions: sterilization of needles, side effects and allergies, potential warning signs of problems. Vaccinations are taken as a given in Kumaon and even integrated into these health meetings – in fact, I note that next to the ANM is a cooler full of vaccine vials: an explanation for the kids that roam around the room during the meeting, waiting for their vaccinations.
As another woman speaks loudly about how the power of the purse should be given to the local people and not the Block Development Officer who “spends half of it on antibiotics or medicines that are not needed, versus chlorine tablets which are needed,” some of the ASHA workers pass around large folded cards that spread out in an accordion fashion. As I look at the depictions of syringes and sick or breastfeeding women, captioned by Hindi words, I realize that this is the mechanism through which ANMs educate mothers about antenatal care and how they keep track of child vaccination schedules. Each registered child has a card that parents bring to the ANM centers or health camps every time their child is vaccinated. No computer print-out, no form to fill out for school entrance. Just an all-inclusive brochure-log.
But if parents are responsible for bringing the card to health camps or ANM centers to vaccinate their child, how can they be held responsible for getting the vaccinations done? I find how the system works interesting. In the U.S., regular check-ups with pediatricians and accountability by school entrance mandates keep children on track. Here, they use the power of the community and the word of mouth. ASHA workers reach out to families in educating and making them aware of ANM centers, of institutional birthing, of the need to vaccinate children, and of health camps. They also record and keep track of registered births, so while parents have to be the one to actually go to the ANM center, ASHAs will keep parents accountable (and knock on their door) if they fall off the vaccination track.
The same goal of vaccination. Different ways of approaching it, dependent on the context and culture. It is in this pattern that rural health functions. While villagers may not have immediate access to roads or to doctors and hospitals, health instead comes to them in the form of VHSC meetings, ASHAs, health camps and local ANM centers. While this structure of health is relevant for all health problems, it is especially important and crucial for the universal phenomenon of pregnancy and childbirth – how does antenatal and postnatal care occur in households sparsely dotted around the rugged mountains? What are families’ practices, beliefs and behaviors; structural issues; and medical issues in regard to this, and how could this contribute to neonatal mortality? This is a topic I am focusing on while I am here, and I will elaborate upon it in posts ahead.