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Hello everyone, I've been 'on the go' for the past week or so and processing all that I'm experiencing. I have had a few more experiences than what is in the following email (another wedding, more field visits to different villages, weekend trips, dancing etc). What follows is a long, general overview on first impressions and thoughts of my host organization and involvement. I'll send other emails about my other experiences some time as well. *** I became acquainted with my host organization and supervisors last week. Action Research and Training for Health is a private non-profit nongovernmental organization that specializes in child and maternal healthcare in the three village communities outside Udaipur. ARTH aims to increase the quality and access of care to these marginalized, rural communities. My supervisors, Drs. Kirti and Sharad Iyengar, founded the organization ten years ago. They picked Rajasthan as a focus because of the health need and poverty of the area and Udaipur for its relative access to surrounding tribal populations in villages nearby. Dr. Sharad is an educated, professional, and direct man who genuinely wants to match my skills and interests with the outreach missions of ARTH. ARTH combines clinical facilities and expertise, scientific research, and health advocacy in its outreach. During the past week I've basically read a variety of materials and health studies ARTH has carried out over the past decade to get me oriented and acquainted with the organization as a foundation from which I can begin my work. I also visited two villages one day where ARTH operates clinics and self-help groups. When Drs. Iyengar first entered these communities they pictured their new organization as a public health intervention. What they found were communities in dire need of sexual/reproductive, maternal, and child healthcare. On almost every level, women are more at risk for disease, abuse, exploitation, marginalization, and death. This is true globally in most developing countries, but is even more exacerbated when it comes to health for Indian women. The barriers between people and good health are enormous in general for India. Gender, caste, tribal status, language, religion , education, literacy, poverty and rural vs. urban setting ALL affect the status of women and access to health care. Consider maternal mortality, a bellwether for women's health. In India, it is around 420-570 maternal deaths per 100,000 births; Indian women have a lifetime maternal death rate of 1:55. In Rajasthan, the state Udaipur resides within, maternal mortality is 670 per 100,000, one of the highest in the world. For comparison, US maternal mortality is 8.9-12.1 per 100,000. Drs. Iyengar first carried out a three year long study to comprehend the demographics of the communities they planned to engage. Work over the last 10 years has, of course, diversified from this initial survey. Just to give you an idea of one study (this is for only one community of 10 villages from now 10 year old data - but it gives some perspective), here are some highlights. Half the villagers are from the lowest qualification of tribal status. Less then 10% of women and half of men are literate. Most attempt to make a living off of agriculture. By the time women are 25-39 years old, they have had four children. Half of these women had at least one of the following: a still birth, spontaneous abortion, or a child death. The median age of marriage for a woman is 14.6 yrs – two thirds of adolescent girls and one third of adolescent boys (13-19) are married. Cohabitation starts 2 years after marriage. And I haven't even scratched the surface of maternal morbidity and mortality. Let's just say it's not good at all. Most give birth on a dirt floor in their homes with no access to a doctor or trained nurse-midwife. Virtually no antenatal, postnatal, or neonatal care existed before ARTH intervened. If a complication or obstetric emergency arose, people would seek help from a quack, faith healer, or try to get to the city. To reach Udaipur, a poor husband would have to immediately raise thousands of rupees (Indian currency) to rush his sick wife to a bus or van down a bumpy road to finally reach a hospital 50-70km away. He'd be greeted by Indians who spoke another language and looked down on tribal members. By this time it might be too late for the mother and/or child. All of this is, of course, if the extended family concurred the woman should go to the city. Taking all data and community experience into account, the Iyengars decided to implement plans to improve child and maternal health by offering clinical services and introducing comprehensive family planning, contraception, and safe abortion services. Sexual and reproductive health is difficult to discuss and engage in any setting. Personal discomfort and embarrassment combine with the political, religious, and ethical underpinnings of this wide-ranging issue. I am a bit apprehensive about my involvement in an organization that advocates and carries out abortions. This isn't because I classify myself as "pro-life" but rather because I genuinely do not possess personal, moral clarity on this issue. I am on "on the fence" at this point in my life. I do not think it is an act of moral cowardice to be "undeclared" at this point either because I am actively "wrestling" with this issue. Dr. Sharad congenially described to me that ARTH viewed itself as a public health organization when it entered these communities. When they arrived, abortion, specifically "safe abortion" was a problem in the community (more on that soon). Dr. Sharad declared ARTH is not composed of "abortion activists" by any means and does not expect intern volunteers or ARTH members to "raise a flag to promoting abortion." After examining the community and realizing other NGOs were not engaging this issue, ARTH decided to act. Reading more of ARTH's research and visiting the field gave me greater insight to the factors contributing to initiate safe abortion service among the wide range of activities to improve child and maternal health status in these communities. We took a van from the city winding up into the hills of the Aravelli Range. The muddy highway had yet to be completed, but we eventually turned onto another winding semi-paved road to the clinic 55km away. Situated in a pink building not far off the main road, the clinic comprised of a two-level concrete building with several rooms, no running water, and sporadic electricity. Some women and children were already lined up to receive care. Since it was a rainy day, most people were out in the fields plowing and tending the newly wet earth. Lives revolve around the rains. People subsist on one crop per year. Rain means crops, food, dignity, and life. Drought brings famine, government intervention, disease, indignity, and death. Dr. Kirti attended to women upstairs while I observed Dr. Sharad treat children, offer public health advice, and chat with the rare man who accompanies his wife inside. Most of the services in the community are carried out by nurse-midwives hired or trained by ARTH since the doctors do clinicals only twice a week. Plus these local nurse-midwives know and live within the community to deliberately offer 24hr care and act as patient advocates when a complication demands a city referral. A rudimentary lab consisting of a table and a handful of chemical reagents also existed in the pediatric room. The technician carried out urinalysis, blood tests/typing, ( e.g. anemia), pregnancy tests, TB sputum tests, malaria tests, and sperm motility examinations among others. Dr. Sharad then took me for a walk through the community. Near the "town square" Dr. Sharad mumbled, "Ok, up here look to your left, but don't be obvious and look away." As I did so, a man noticed us and quickly closed a curtain to his makeshift shop. The man was a "Bengali doctor" – a quack. Decades ago the state of West Bengal made it easy to obtain some sort of medical certification without any substantive training. When they discontinued it, the unqualified practitioners had become a cultural norm and continued to practice through apprenticeships. Many exist without any billboard sign and pop-up in villages to render their services to the poor and illiterate who have no other health care access. Most give some form of injection or herb as treatment. Some provide abortions. ARTH attended patients who received botched abortions or heard of those who were killed by the attempts. When village families complain to the government officials, who are bribed by the quacks to set-up shop in the first place, the government sweeps in and all the Bengali doctors vanish in a wide area to avoid the crackdown. After lying low for 3-6 months, like parasites, they return. A significant part of maternal mortality (teens in percentage) in this baseline study were due to the practice of these unsafe abortions. Dr. Sharad noted that since ARTH engaged the community it has "taken the market" with access to safe abortions from such quacks and unqualified practitioners. I'm still learning about the other complexities and motivations for providing this access to the community (women's empowerment, family planning, reproductive health rights, and abortion's legality in India since 1972). Abortion is not a controversial issue in India. Intending not to deflate the moral weight of abortion, but rather to make a cultural aside, Dr. Sharad stated that some people in India would have as passionate arguments/dialogue on the ethics of vegetarianism as people have on abortion in America. Back at the clinic, I watched as Dr. Sharad described to a man how to use a condom. Afterwards he said, "You see, I may have just prevented an abortion." I looked online the next day for information and found a statistic put out by the Alan Guttmacher Institute in 1999(which I guess receives funding from Planned Parenthood (it's always good to know funding sources and thus influences on these stats)) that women in the US who use "a method of contraception are only 15% as likely as women using no method to have an abortion." I found Dr. Sharad's comment and this statistic interesting. But to put this all in perspective, ARTH again spends a lot of time and energy in overall child and maternal healthcare – and I'm still learning what all it does. For a global perspective, 510,000 women die every year of maternal conditions. 10.8 million children under the age of five die every year – 37% die within 28 days of birth, the neonatal period. An ongoing four year study with other NGOs aims to reduce neonatal mortality in ARTH's outreach community by HALF. The doctors are interested in me integrating HIV interventions into their existing sexual and reproductive health programs. HIV prevalence is low here, but infection occurs from men migrating to cities and coming home to infect their wives (much more on that later). In any case, I'm learning here and engaging the world we live in. In regards to my perspective on this first work week, contemplation on medical/social ethics, and my experience here overall, I take part of the traditional Benediction as my theme. I'm going out into the world in peace. I'm attempting to hold on to what is good. I aim to return no one evil for evil. I intend to strengthen the faint hearted and help the weak. And I aim to love the Lord with all my heart – this day and forever more. Keep in touch, Will P.S. UNAIDS, USAID, and NACO released new statistics on estimated HIV prevalence in India. I knew about this before I left and this has been expected by the international health community for several months. Estimates of 5.7 million infections, 0.9% prevalence are now at 2.5 million and 0.36% prevalence (from first in total numbers in the world to third in total numbers). New and better data that included a population based survey of over 100,000 people from a wider geographical area and number of sites for blood tests was used. The older data used sentinel surveillance at antenatal clinics which screened in high prevalence areas at fewer sites. Thus these new data give better insight into the complex and diverse epidemic in India. See the below web link for more details. http://www.unaids.org/en/MediaCentre/PressMaterials/FeatureStory/20070704_India_new_data.asp |