“It would take armies of medical professionals and mountains of money to treat the millions of Indians who have health problems. Yet 98% of the most common diseases are preventable. My aim is to demonstrate that it costs almost nothing to promote health in a way that prevents precisely those diseases.”
Dr. Frederick Shaw, Founder, Developing Indigenous Resources.
CHILD ADVOCATES FOR SOCIAL EMPOWERMENT (CASE) / Janta Colony, India, 2009
One doctor, one nutritionist and a team of 16 locals armed with bathroom scales. For public health specialist Dr. Frederick Shaw, that’s almost all it takes to break the cycle of poverty and disease for 14 000 people who live in a slum on the outskirts of Chandigarh. Developing Indigenous Resources (DIR) is the culmination of lessons learned over Shaw’s 40 years of field work.
Through daily training given by DIR experts and other volunteers, Shaw has turned 16 slum residents into Health Promoters (HPs). The weigh scales they carry are the “way in” to people’s homes. Every month, HPs monitor the growth of every child under the age of five; the visits create an opportunity to discuss health concerns, provide advice on nutrition and assess the family’s overall well-being.
Janta Colony is home to 14 000 people. But you won’t find it on any state or city map, an oversight that lets all levels of government consider it a temporary slum or ‘basti’ in the local slang.
Such programmes are vital to India’s invisible masses. The first time Shaw sought government help for his work in Janta Colony, an official argued there was absolutely no reason to direct public health funds towards that region. State law makes it illegal to live in a Forest Reserve Area and so, quite obviously, no one does. When Shaw pressed his case by recounting how residents have built up their community over the past 60 years and described its persistent sewage problems, the official pushed back.
“Thank you for your visit Dr. Shaw,” he said. “Please understand that if I were to discover you in this area, I would be obliged to charge you with trespassing on a forest reserve and put you in jail for two weeks.”
Clearly, DIR’s philosophy of empowering people to solve their own problems is the right remedy.
Veena (29 years) and her sons are third- and fourth-generation residents of Janta Colony, where she now works as a DIR Health Promoter.
Situated on India’s northern plains, the basti is hot and dry much of the year; temperatures can soar to 45°C or more in the summer. Even in late November, just before the winter cold sets in, it is warm enough at 9:00 am to enjoy being on an open rooftop. Veena joins 15 other basti residents for 20 minutes of yoga. It is a time to put some distance between their daily lives and their roles as agents of change.
Over 15+ years, Developing Indigenous Resources (DIR) has given this team of Health Promoters (HPs) daily training in health fundamentals, including a strong focus on nutrition and disease prevention. DIR believes that three inexpensive pieces of equipment – bathroom scales, stethoscopes and blood pressure gauges – can be powerful tools to monitor the general health of residents.
Each HP is responsible for 200 households in Janta Colony. One of their main jobs is to track, on a monthly basis, the weight of every child under the age of five years. These visits create a natural opportunity to share knowledge on many health-related topics.
As in most slums, general poverty makes malnutrition a primary concern; but high rents in Janta Colony contribute to a higher incidence of severe cases. Champa (22), together with her second baby (2 months), barely pushes the needle on the scale to 34 kg.
For DIR, monitoring child health begins at the earliest possible moment. HPs visit pregnant mothers every month to monitor weight, blood pressure and foetal heartbeat. Often, their visits are a kind of ‘community health’ as friends and neighbours listen in.
The effects of early malnutrition can be life-long. Chandigarh doctors attribute Prem’s blindness, at least in part, to his mother’s severely malnourished condition during pregnancy. In addition, he was born at home in a remote village with no immediate access to medical care.
DIR HPs are recognised for more than their blue jackets. Basti residents such as Rangeelie, particularly those with little or no education, have come to view the HPs as local experts and welcome their arrival.
As most homes in Janta Colony have only one or two rooms, much of daily life transpires outdoors and even very young children are exposed to the elements.
By mid-day, a self-inflicted blast of cold water on the front porch can be sheer delight, but most homes lack running water so having a bath starts with hauling a bucket.
But water is a serious problem in the basti. Poor maintenance of limited drainage systems leads to back-up of waste water. Within steps of every doorway, non-biodegradable matter floats atop fermenting organic waste while a variety of insects, including malaria-bearing mosquitoes, skim the surface.
Traversing the basti invariably means passing within inches of wide expanses of open swamps or equally contaminated creeks (nullahs) that flow between rows of tightly packed houses.
As HPs got to know the families in their sectors, they realised that many women work long hours cleaning houses or selling goods in the streets of Chandigarh. It often falls to the eldest child to carry out household chores and take care of their younger brothers and sisters.
The biggest risk for basti children is contracting diarrheal diseases from poor hygiene, contaminated food or dirty water. For infants and toddlers, severe dehydration can spiral downward to death in just hours. DIR makes it a priority to teach every woman how to mix an oral rehydration solution from basic kitchen ingredients: boiled water, salt, sugar and baking soda. A squirt of lemon masks the terrible taste.
Sometimes, as in the case of Madhu, the child left in charge may be no more than seven or eight years old.
When DIR recognised the responsibility older kids carry, it began an after-school programme for those aged 9 to 13 years. Child Advocates for Social Empowerment (CASE) uses fun and games to teach basic health and hygiene. Participants like Ruby are encouraged to share their new knowledge with their parents and siblings.
HPs devote late afternoons, the most likely time to find women at home, to giving courtyard cooking classes. Menus are carefully prepared by DIR’s nutritionist to derive optimal benefit from locally available fresh produce and to keep prices at less than two rupees per person (CDN 0.05 or EUR 0.02).
A more subtle aim of CASE is to promote the social and physical development of these pre-teens by making sure they have a chance to have fun – away from the family responsibilities.
Vaishakha’s birthday party was a sign of success. The menu included cake and snacks, but also a well-balanced meal of rice, dal and vegetables. Her mother and aunts used to believe that “expensive” food equalled healthy food. Following HP advice, they’ve stopped buying processed foods and watched their collection of eight children move from the “Red” to “Green” Zones on DIR health charts.
DIR statistics, confirmed by an independent assessment, show that the HP strategy is working. The incidence of severe malnutrition amongst children dropped from 87% in 2004 to 40% in 2010, and almost 100% of basti women gave birth at the hospital – compared to the national average of only 41%.
HPs also remind mothers about upcoming immunisation clinics held in the basti and assist government officials. As a result, immunisation rates are 85% to 93% (depending on the disease) compared to 55% to 78% nationally.
Despite these positive gains, deeper analysis showed that DIR’s efforts were having the least impact on the neediest children. Monthly visits were not enough to make a difference for those who are “grossly underweight” – a condition that creates high risk for other health problems.
Jyoti is one of the most severe cases: at 16 months, she weighs only 5 kg, yet her stick-thin legs are too weak to stand on. Her pale hair, skin lesions and protruding ribs suggest the onset of protein energy malnutrition. Desperate for nourishment, her body is drawing on its own reserves of muscle and fat.
DIR’s “School with a Difference” prepares pre-schoolers to win scholarships at the best private schools in Chandigarh.
During one of her visits, Ruby starts by showing Jyoti’s mother how to mix the oral rehydration solution. Later, while helping bathe and dress Jyoti, Ruby lectures the mother about keeping the house cleaner and preparing more balanced meals.
The CASE contest was a success on many levels. Basti residents are demanding more street theatre and 31.6% of the grossly underweight children gained at least 1 kg. For some, this represents a giant step toward reaching the Green Zone. According to Dr. Shaw, this philosophy of empowering people to solve their own problems is the key to the DIR model. If DIR disappeared tomorrow, the skills and knowledge it has taught HPs and residents would remain intact – and easily passed on for many generations.
