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How little conversations about health are invaluable in precipitating big changes in a community’s health status

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This week Deepak sent an email around that excited Neha and I a little bit (to say the least!) – there are some women in Bakhel that would like to make bathrooms. Why’s this so exciting?: Here’s an excerpt from a piece that Neha wrote about bathrooms and female privacy and hygiene a few months ago:

Every morning in September was the same: after being startled awake at 5:00 AM, I would pick up the small purple jug, fill it with water at the handpump, and then head out to the fields to “become fresh.” It was time for all the women of the town of Mandwa to go and defecate. In one respect, it was female bonding time; we would nod or say Ram Ram as we passed each other in the near darkness, acknowledging that we were all here for the same communal activity. In most respects though, it was terrible. For the first few weeks, there were mornings when I just didn’t have to go, but I had no other option. Simply put, it was go now, or wait until the next morning.  And when stomach problems struck, as they inevitably do during the first few months in rural India, it was excruciatingly awkward, as there was no appropriate place to go during the daytime hours.

She goes on to say:

In Bakhel, and in many of the surrounding villages, women literally have no privacy at all, which turns seemingly normal daily activities into difficult, trying endeavors. Besides restrictions on when and where they can defecate, women also face limitations when showering. There are no closed-off bathing areas in Bakhel, so everyone showers entirely in the open. In my area, breasts are not considered taboo, so women can use soap on the upper-half of their body. But women in Bakhel always shower while wearing their ghaghras, or long skirts, and in many other villages, women shower completely clothed. It is nearly impossible for a woman to properly clean herself if she bathes with clothes on, and feminine hygiene becomes even more of a problem during menstruation. A menstruating woman can only try to become clean in the dark of night, secretly washing her menstrual cloth when no one is looking.

Due to this lack of privacy, women’s health is greatly affected. A woman in Bakhel might not seek treatment for diarrhea, or will try to deny she even has it, because a woman should not be seen going to the bathroom outside the specified night hours. She might develop a urinary tract infection or vaginal infection from insufficient hygiene, but feel too embarrassed to acknowledge it until it is incredibly serious. She might not even know she has an infection, because a typical woman in Bakhel has never seen herself naked- she has no idea what looks healthy for her body, and what it looks like when something has gone wrong. She will silently suffer, rarely consulting with others, and just accepting it as the norm for her life.

One step to dealing with this is to build latrines near women’s houses/ a latrine for each home. But one cannot simply just go ahead and build and expect people to use it, even with “induction”, “orientation” or “training”. Lives are complicated, old habits die hard, and while we may see great benefit from having such privacy, the women haven’t experienced this before so may be unsure of what benefits it will bring:

However, just building latrines and bathrooms is not enough. Women need to believe that they deserve privacy, that it is their right to be able to take care of themselves and to be healthy. Right now, in Bakhel, women do not see their lack of privacy as a problem- it is just the way things are. Thus, the first step is bringing this issue out into public, and talking about it as openly as possible, to let women see how much healthier and happier they could be if they had a bit of privacy. Yet getting it out in the open is easier said than done. Even writing this, I felt a little awkward, but if I can’t feel comfortable talking about it, then how can the women in places like Bakhel, where such topics are unmentionable, start bringing them up?

In understanding the need to talk openly about such issues Neha, Vishnu Priya and Pushpa were able make the Hunar Ghar women’s meetings safe places of open discussion about many issues affecting the village and the community, including personal hygiene. This has let over time to a genuine demand from certain people within the community – five people, to be precise – for such facilities. Deepak and the team have discussed the possibility of and Hunar Ghar involvement in these bathrooms, and come to an agreement: Hunar Ghar will provide support and ‘labour’ from our staff, as well as material from the sides of the basic bathrooms, the women will do the building and provide bamboo for a basic structure.

To return to my original statement, I find this very exciting. There are several reasons for this.

  1. There has been a forum opened up for women to talk about personal health issues in an increasingly openmanner
  2. Some women have understood Hunar Ghar to be a resource they can use to turn their new understanding of personal health issues into concrete steps towards improving their families health
  3. They are acting upon this, and in discussions with female and male Hunar Ghar team members, organising the implementation of their right to better health
  4. Community health status will improve
  5. The public construction of a bathroom is a sign that people in the community are now ready to do things differently from other people: they are starting to prioritise their personal and community development over the fears and taboos of yesterday.
  6. Such openness is a significant step along the way to other female health improvements, such as access to and use of gynecological care.
  7. The demand came from within the community, and Hunar Ghar is being understanding and responsive to these needs.
  8. There is a  sharing of expenses, effort and responsibilities between the individuals of the community and the Hunar Ghar team
  9. Hunar Ghar’s responding to the needs and requests of the community members demonstrates that we listen, care, and are supportive. This will lead to greater use of Hunar Ghar as a community resource in the future.
  10. Our Hunar Ghar team are happy to be doing these types of activities on Sundays and holidays – this is extremely unusual for “school teachers”: Our Hunar Ghar team are embracing the idea of Hunar Ghar being a shared learning space where everyone supports one another – the 9 to 5 day is becoming a thing of the past. In it’s place there is inspiration, energy and collaboration.

Every single one of these is significant in an of itself. It may be only 5 latrines in one village of the hundreds of thousands in India, but for these 5 women and their daughters, and then the next 5 women, then the next 5 … it is deeply meaningful, incredibly valuable, and worth recognising and celebrating.

Making mobile even clinics more meaningful

By community participation

At the end video Hunar Ghar coordinator Deepak sits with a patient to ask him about his experiences with the mobile clinic. Next month, we plan on a full survey of all patients so we can include the needs and perspectives of the community as much as we can in the style, type and manner of health care they receive. 

The latest monthly mobile clinic, hosted by Bakhel and provided by the Global Hospital & Research Centre in Mount Abu, happened last Sunday. This month we were visited by 64 patients. This is down on the number of patients we usually see – more than 100 every month – but there is currently a lot of work in the fields as people prepare for harvest, or fertilise all their cotton.

There have now been 4 mobile clinics, and each one successful. It is becoming know that this is a regular and reliable form of finding healthcare, something the Bakhel community has perhaps never had before.

Except there is one problem

The word in the field is that lots of people don’t want to use it.  Odd, no? – free reliable healthcare from trusted and caring doctors brought right to the door step; who wouldn’t want to use that?

The first person is someone that has multiple  illnesses or suffers chronically. Although the doctor makes, for example, TB referrals,  the mobile clinic service is not equipped to deal with many chronic illnesses, and these are sometimes the most threatening diseases to a lot of people in Bakhel. The clinic also only come once a month, so there is no chance of further consultation say two weeks after seeing the doctor – making diseases that cannot be treated with a few days pills and tablets harder to address. Pills and tablets are also the only things that the clinic is equipped to dispense. In the village there is a general low interest in pills – they want injections, and they can’t get these at the mobile clinic. They want injections because they see these as treating more serious diseases – something we have seen the mobile clinic is less able to do.

Another person that isn’t going to come may be a woman with health issues. Most mobile clinics it is a male doctor who comes, which presents immediate issues. The doctor also operates out of the back of the van you can see in the video above – and the cluster of people you can see outside it are all patients waiting in line – there is absolutely no privacy or patient confidentiality.

So what can be done?

The Hunar Ghar team and I had a discussion about this after the clinic. We decided that there were some simple things we can do to improve the situation, and there are some longer term changes that we will need to find a way to work out. Next month we are going to ask the doctor to sit in a private room in the house behind, so people can speak more openly. We are going to tell each female patient that if they prefer they can  speak privately to Vishnu Priya, a female from the Hunar Ghar team. She will then relay information to the male doctor, so the female patient will be able to discuss issues she might not have wanted to to a male doctor. In the long term we can advocate for a female doctor to come.

Understanding chronic illnesses is a bigger problem. In April we did a complete health survey of the village. In this 5 major diseases were identified. These corroborated with those we thought were the major diseases, but now we have hard evidence to demonstrate it.  In every mobile clinic sine them we’ve been noting down the prognosis of every patient. This last clinic we also wrote down the prescriptions given. What we will do is compare the major diseases identified in the health survey with the most commonly treated illnesses in the mobile clinic. It is my feeling, from scanning through the data, that the two do not align. This means that the best health service the Bakhel community have access to doesn’t address the most common (and pressing?) illnesses – clearly work needs to be done.

The mobile clinic is a wonderful addition to the right to access quality and reliable healthcare by the Bakhel community. It is a pleasure to work with a dedicated and caring team, and this sentiment has been echoed by the Hunar Ghar staff, who see how the doctor treats every patient with kindness and care – not common for the Bakhel community. Most importantly, it is the Bakhel community themselves that have noted that the doctor is good and giving them good attention.

Next steps

With this now in place and running smoothly, we can now bring together the Health Partnership team again – the Global Hospital, the RNT Medical College, Hunar Ghar, the Bakhel Primary Health Clinic and the Bakhel Community to work out what our next steps will be for 2013, to continue to improve access and use of quality health care for the Bakhel community, and make best use of our most knowledgeable people – the Bakhel community  – to help improve health service in other places too.


First mobile health clinic

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The mobile clinic 

This Sunday was the first mobile clinic held in Bakhel after our recent health survey. 103 patients were seen with 97 getting treatment and 14 being referred for further TB and cataract tests. From speaking to Neha it seems like it was pretty great day. 103 people is a good turn our, and several people in the village went above and beyond to ensure people knew about it and came along.

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Doctors & patients

See more photos in the gallery here