Village Health Workers

Wow, have we fallen behind on things! We went away for a couple of days to Aurangabad on “holidays” and even more things happened, not to mention we actually have school-work to do, so I’ve been remiss in keeping you up to date.

Looking back, the next thing we learned about—well, experienced- were the Village Health Workers (VHWs). For those who missed it, VHWs are women chosen by their community to come to Jamkhed to train. Initially they came for a few months of intensive training, although now that the project is so established they just go “intern” at another village with another VHW and get on the job training. But I’ll tell about the original model, which is how the women we met were all trained. Since many of these women have little or no schooling, the training is not typical classroom training with textbooks and notepads but rather involves songs, story-telling and experiential learning, especially lots and lots of role-play. My favourite kind of medical education!! They are taught everything from nutrition and hygiene to how to identify leprosy, information about good nutrition for pregnant women and how to take blood pressure readings to how to deliver babies and understand signs of foetal distress. We’re not just talking about band-aids and temperature here, we’re talking about real medical care and real skill building and these women were given the tools and the knowledge to provide this health care in their village.

In a Western, litigious society, we think about all the what-ifs and reasons why this can’t and shouldn’t work. But this is in a rural setting with no clinic nearby and hospital services far away with access on dirt roads impossible for some with no vehicles and expensive upon arrival. This health care was the alternative to none-at all and it has proven to be an excellent alternative. Maybe better than some Western options, as you’ll see when I share some of their stories.It's interesting that as the VHWs are established in their villages, they eradicate infectious diseases like TB (virtually gone from the villages CRHP works in and yet rampant in other parts of India) and leprosy. However, heart disease and diabetes are rapidly on the rise in all of India as more people spend time behind desks and start eating processed foods and the VHWs are learning to screen for this and educate people about these issues as well. They are also quite well-versed in mental health issues and in many villages, depression is less stigmatised than it is in Australia!

Dr. Arole’s model is to get women of various castes from different villages all learning together so they can start to break down some of the class (and caste) divisions among themselves so when they go back to their communities, they know it can be done. It is hard for low caste women to go to their communities and convince the high caste women to let them treat their babies, but once they see that the low caste babies are thriving, they generally come around. Over and over again we’ve heard that it takes action not words for communities to believe in the ability of the VHW. The Health workers are fighting against traditional beliefs- for example, it is common practice not to breast-feed babies for the first 3 days after birth when there is lots of nutrients in the milk. Another common practice is to keep feverish babies very warm, rather than putting cool water on them. Sometimes, pregnant women are taught to avoid certain foods. All of these traditional practices need to be re-taught by the VHW who is going against generation after generation of belief and practice. Having her, a member of the community, to start to break down these myths is far more effective than having a western health workers come in and do so, but it still takes time.

We were in a classroom and 6 VHWs came in, along with Shayla, one of our teachers who served as translator. One by one the women shared their stories (I won’t tell them all here). There was Sambi, who has been a VHW for 26 years, yet can’t be older than me. She told us how she was the fourth of 4 girls in her family, but her sisters were all married off so young she never knew them. She was married at 12 (the same time I was studying my Bat Mitzvah portion and reading Judy Blume books) and her husband did not ask her father for a dowry (a tradition here in India is for the Bride’s father to pay a hefty sum to the groom to take his daughter off his hands). What the family didn’t know is that this man was already married. Sambi delivered her first baby, a girl, when she was 14-years-old.

On a side note, a girl baby is always a cause for disappointment and is an excuse for the mother-in-law and husband to punish the wife, often violently (one particularly horrifying statistic we learned in our seminar on the status of Women in India is that 55% of Indian women TODAY believe it is normal and acceptable to be physically abused in their marriage and many women feel something is missing from their marriage if their husbands DON’T beat them.) It is one of the many ironies of India that when a woman bears a daughter it is her fault and she is blamed but when she has a son, the husband is praised and given the credit.

In any case, Sambi’s daughter was one of twins, but the other baby died. She had gone to her parents’ house to have the baby and her husband came to visit but his other wife was suing him for divorce. She went back to Pune with her husband but eventually left him because he as violent and had debts to pay to the other woman, and went back to her village at 16, with her daughter in tow. Her parents couldn’t really take care of her though and she was scared and alone with no brother and no son…she didn’t know what she would do and she became depressed. A woman in the village talked to her and told her she could sit tall and stand on her own feet and told her about being a VHW. She slowly, slowly learned and got people to listen to her and eventually, she helped the people in her village and then, got a loan from Dr. Arole and bought two embroidery machines and started sewing and now she owns a 4 BR house. Her daughter is 12 years old and her husband came back to her. Before she took him back, she made him take an HIV test. Now, she is strong and feels happy and secure.

There was also Rekha who has been a VHW for only 10 years. I’ll tell her story in the first-person: “I was low-caste. When I was training at the compound, Dr. Arole had me make some bread for everyone and I said no one would eat bread from my hand but the others took it from me and it made me feel so happy for the first time in my life people took something from my hand. I thought to myself, this isn’t health education- this is love education. We (the VHWs) all have the same brain as we had before but it was locked and Dr. Arole had the key and opened it up. “ Rekha uses songs in her community to educate people about nutrition and sanitation and started a community group with others. Her singing has been featured on National radio and she even got to go (in an airplane) to Calcutta to sing.

A third VHW we spoke with has been in the role for over 30 years and she told how she was married at the age of 2. Yes, 2. TWO. Her husband was much older than her and she was widowed with young children and had nothing; being a VHW saved her life.

VHWs don’t get paid for their work, but they are privy to learning about government schemes and they also get involved in Women Self Help groups which are income generating groups—which I’ll talk more about in another blog.

This is getting lengthy, so I’ll just list a few of the successes these women cited in their villages as they proudest accomplishments

• We worked together to build a road (this may not seem health related but improved access means quicker ability to get to the hospital when needed as well as better access for government trucks to deliver rations and better opportunities for income generation. Lack of isolation =improved health.
• No child under 5 years old has died in my village for over 6 years now
• When I started as a VHW, there were 20 leprosy patients living outside of houses, (stigmatised)…now, they have been given medication and most escaped permanent deformity and all of them are back with their families in their homes because the stigma is gone.
• I have taught my village that cleanliness is very important. Before, children were defecating everywhere. The Women’s group and the Men’s group (farmer’s club- tune in next blog!) worked together to teach about hygiene and now no one defecates near the water we drink.
• Everyone has healthy pregnancy and knows what to eat.
• In my village we try to make sure the adolescent girls don’ t marry before 18 so she can have a healthy baby.
  
• We teach about immunisation

A few interesting comments in contrast to western medicine:

1) The VHW who married at 2 has delivered over 300 babies and only 6- SIX!!! of them were Ceasarean (performed at the closest hospital-- as I said, the VHWs are taught to recognise signs of foetal distress, breech positioning, etc. and when necessary, do send women to hospital- often by motorcycle!!) So perhaps it is possible that at least some of our c-sections are unnecessary?!

2) One really interesting comment is that when asked what they do with a woman who can’t produce enough breast milk for her baby is that among all of them- with over 100 years of combined years of VHW experience and countless births, there was only ONE incidence of a woman not being able to breast feed.

It got us all talking about whether there could be environmental factors or a different level of patience in terms of how long we try before we allow a mother to decide she “can’t” do it…not trying to start a la leche war here, just thought it was interesting.

In any case, I don’t mean to gush- I’m not really a gusher- and I’m not easily impressed, but the stories of these women- and how Dr. Arole has transformed their villages and their lives- is truly amazing.

Next up- the Farmer’s Clubs...these are the men’s groups…where it all really begins!

Here is a few shot of these great women: (Shayla, our teacher, is the 3rd from left)