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Studying health in rural India

Talk for Friends of St Paul's Cathedral, 2006-04-06.
Repeated at Melbourne Unitarian Peace Memorial Church, 2006-07-23.

Table of Contents

1 Introduction

Talk about a visit to a rural health centre in India that has enabled
people to improve social and physical conditions. Demonstrates value
of humility over hubris on the part of health professionals.

Part of my Master of Public Health studies. Public health is the use
of many professional disciplines and techniques to understand and
improve the health of wellbeing of communities. It has a broader
scope than professions like medicine or nursing, which are usually
focused on individuals. Public health isn't just concerned with
biology. It is more concerned with building systems to make health
care accessible, to evaluate how well these systems are working, and
to teach people about all kinds of health issues.

The University of Melbourne runs a short course in collaboration with
the Comprehensive Rural Health Project in Jamkhed, India.

Jamkhed is a small town in Maharashtra, a state in central
India. Mumbai or Bombay is the largest city in this state, Pune is the
nearest large city. Jamkhed is inland, and most of the people who
live in this area are farmers. In 1970, Raj and Mabelle Arole, two
Indian doctors who had studied in the USA, returned to India with the
aim of building a hospital that was accessible to the rural
poor. After some false starts they settled in Jamkhed. They built a
hospital but also realised that to maintain good health, the people
needed clean water, education and self-esteem. The Comprehensive
Rural Health Project that they established has become a model for
other parts of the world where people cannot afford expensive,
high-technology health care.

The programme in Jamkhed has a training centre where people from
India, Nepal and other developing countries learn about the Jamkhed
model. Three years ago the University of Melbourne started sending
students there for short courses. Some of the Australians who go
to Jamkhed are interested in working in developing countries. Some
want to learn about reversing the effects of inequity and
discrimination. Australians can learn a lot from Jamkhed because the
Aroles haven't just tried to give the poor the same things as the
rich. What they have done is give the poor the power to improve their
circumstances themselves.

In January I went to Jamkhed with 17 other students, two lecturers
from Melbourne and their children. The students included nurses,
speech pathologists, a physiotherapist, a pharmacist and a doctor.

In the spirit of CRHP, we learnt from local people as well as experts:
visits to villages, talks from village health workers and CRHP staff,
and lectures from Raj and Shobha Arole.

2 What is Primary Health Care?

CRHP is a model of PHC.

In a developing country context, primary health care means an approach
to health care that is holistic and focuses on how the physical
environment and society affect people's health.

Health systems based on PHC principles are:

  • Essential
  • Socially acceptable
  • Universally accessible
  • Participatory
  • Affordable

2.1 What is health?

PHC uses a positive definition of health:

A state of complete physical, mental and social wellbeing, and not
merely the absence of disease or infirmity. (Alma-Ata)

Health is a fundamental human right.

Holistic understanding of health includes physical, mental, spiritual
wellbeing; ability to maintain livelihood; social relationships.

Health promotion and preventive medicine, not just curing symptoms.

PHC is inter-sectoral: it recognises the importance of agriculture,
infrastructure (sanitation, roads), education.

Cooperation between people from different backgrounds and profe
ssions. Doctors, nurses, community health workers, limb technicians,
educators etc. work in teams with minimal hierarchy.

Complementary health systems: Western and indigenous. In India, this
means being open to non-Western health systems eg Ayurveda, herbal
medicine. Use what is appropriate for the situation.

3 The Comprehensive Rural Health Project

3.1 History

The Aroles wanted to work in a poor area. Consultation with community
leaders, false starts. Wanted to work with the whole community, not
just leaders.

Agriculture is important to people's lives in this area. Don't just talk
about health on its own but address the felt needs of the community.

Women have gone from being treated as sub-human to becoming respected
health workers and leaders.

3.2 Dr Raj Arole

Christian upbringing enabled him to see through traditional barriers
of caste and gender. When he was a child his mother was sent to
Jamkhed as a teacher but could not find a home because she was an
outsider and not a Hindu. Attitudes in Jamkhed have changed a lot
since then, through the Aroles' efforts.

3.3 Dr Shobha Arole

The Aroles had two children. Their daughter, Shobha, is a doctor, has
studied some complementary medical systems like homeopathy, and is
also a minister in the Church of North India.

3.4 Christian values

Prayer every morning for staff and visitors. Not all staff are
Christian but they recognise the value of its social outlook. An
alternative to caste: Everybody is equal before God.

Visit from the local bishop in the Church of North India: Dr Arole is
highly regarded.

4 Society

Inequalities: rich/poor, urban/rural, male/female.

Poor people often cannot afford health care or medicines or can't even
access services -- lack of infrastructure.

Health care needs to be accessible to the many people living outside
of cities without the resources that health professionals take for
granted.

4.1 Caste and Varna

Origins in Hindu traditions.

Social/occupational groups.

Four main Varnas, and Untouchables (Dalits or Harijans) beyond.

People from different castes don't mix with each other, and
untouchables are excluded from normal society, to the extent of having
homes outside the town limits.

Buddhists, Muslims, Christians etc aren't supposed to believe in
caste, but it is so entrenched in society that many non-Hindus follow
caste rules. Gandhi and Ambedkar tried to abolish caste during the
independence movement but weren't successful.

4.2 Gender

Female infanticide and selective abortion mean that girls face
discrimination before they are born. Girls are regarded as useless
burdens. (Dowry is expensive.) They may not get as much food or
medical care as their brothers.

5 Health priorities

Improve maternal and child survival, especially for girls.

Nutrition.

Preventing infectious diseases--hygiene and immunisation.
Many people lacked basic sanitation facilities and clean water.

6 Solutions

Collaboration with local people, responding to their perceived needs
(which may not initially include health).

Help with farming and sanitation.

  • Water: indoor toilets, basic sewerage, education about hygiene

  • Farming: farmers' clubs, supportive groups

6.1 Village health workers

Key to change.

Often women, middle-aged (have experience of childbirth and raising
families). Generally have little education or literacy (because women
didn't have these opportunities).

Identified by villagers, trained by CRHP staff.

Maternal/child health, simple medications, referrals to hospital when
needed.

Educating the village through drama and art.

Child feeding programmes: mixing boys and girls of different castes.

Learning to overcome caste and work with all women.

Women with little education realise that they are as good as men, that
they can understand health and teach others about it.

6.2 Appropriate technology

6.2.1 Herbal medicine

Prefer locally available and effective medicines to expensive
pharmaceuticals.

Catalogue of local herbs/medicines.

6.2.2 Artificial limbs

Made of cheap materials and built for squatting (traditional posture)
rather than sitting.

7 Achievements since 1970

  • Reduced infant mortality rate
  • Reduced birth rates

  • More girls staying in school longer

  • Better self-esteem and community cohesion all round
  • Bringing the model to other regions