A handful of life

Early this week, one afternoon, a newly hatched pigeon chick fell down from its nest and landed on our balcony. The tiny little bird-like thing with tiny wings, pointy beak and large black eyes which were yet to open was actually quite active. It would turn its neck from side to side, tremble sometimes and sometimes roll on its back. We promptly put it in a box lined with cotton cloth and put it beside the warmest of our walls. But other than that, we were at a loss of how to take care of the tiny handful of life.

I called up a few hospitals around and learnt that there is only one at the other end of the city which not only treats birds, but also adopts them and sets them free when they are of age. In the meantime, the household was consumed with spending time with the chick, as though everything revolved around our new friend. After a fitful night of prayers (fitful for us, because the chick did not eat anything we tried to offer), we were relived and happy to see that it still moved the next day. It was then carefully handled and taken to the hospital. Its better off with a trained staff who are professional and not emotional around it.

I also learnt that newly hatched chicks can survive without food for first three days, since they eat the egg proteins just before hatching. Hence those who breed birds, often courier the chicks out within three days of hatching.

Although I would never see it again, every time I go into the room where we put the box up, I am reminded of the little moving ball. I just hope life does not let the little fighter down. My thoughts then came to all the little babies who for whatever reason get abandoned in the first few hours after birth. Some find good homes, others are taken in by family, still others are not so lucky. But those few hours, when every life form deserves care and attention, is lost to probably most babies around the world.

Life helps us cope with loss, by locking them in as rich memories. As time goes by, we smoothen the rough edges of events and sometimes forget what we don’t want to remember.

So, if the present is fleeting, and the events in the present are not long lasting, since with time, they only become more abstract in our minds, then why can’t we be more cognizant about our bearings in the present. Wouldn’t this lead to better and happier memories? Instead of those we would like to forget?

This should probably help us behave better, take better decisions outside of ourselves and laugh more, scowl less?

Memory- A poem by Prabha Trimurty

Like a shell on the beach…

My memory lingers on…

The waves carry them in…

The sand erodes their shape..

The rain buries them low…

The sun shines them gold…

A stranger picks it up…

Seals it in his palm…

Throws it back into the sea

There in the depth of time….

My memory lingers on.

Advertisements

Two of swords

The road ahead splits into two

Which do I choose, which do I not?

Both have a lot of green and grey

Both seem to welcome me to stay

If I tread on one, I may never know

What life’s lessons lay in the other to follow

For I know both have thorns and meadows

A few heart breaks and a few longings for tomorrow

I ask those around me who would know

Those who have walked these paths before

I seek a sign from the skies

I sing a hymn, I close my eyes

And then I hear a little voice

It comes from within me, from somewhere

What is it that you truly desire? It asks

Both roads have the same share of joys and sorrows

Both would help me know myself more

Both would find me new friends and homes

New adventures waiting in unknown roads

I realize road to life is long

Some days filled with boredom, others with enthusiasm

It is only I who can make

My days filled with magic or stupor

It is only I who can create

Good days for hopeful tomorrows

Or bad ones with dreamless sorrows

So no matter which road I choose

I am the one to live it through

I am the one who would decide

Whether I sleep or wish to fly

 

Feminine Strength?

Last month has been truly hectic and tiresome. I had to complete a few project and meeting reports, start on a few new projects that required travelling to villages and districts and my daughter had her school exams. It was more stressful to be around a nine-year old unable to sleep at night and constantly reminding herself of revising essays on topics such as International Women’s Day (which I am sure, she doesn’t fully comprehend anyways). I am not sure what our education system has come to, should children be subjected to stressful exams, memorized speeches on topics that are alien to them? A few of my friends have opted for more unconventional schools with novel methods of teaching, more similar to programmes that ran in ancient India, where children were taught more by observing nature instead of chapters to memorize. I have often thought of letting my daughter be in one of those schools instead of the one she is presently at. I have to find the time to do some school research too.

At one point during our tiresome week, we were both too fatigued with work, home and studies. One evening, I just gave up and sat with her doing nothing. We listened to soothing music, danced around with Tina Charles and ate a warm plate of ketchupy, spicy, egg fried rice. We did have a great sleep that night and promised ourselves to do this more often.

I also thought about the women public figures in my life who have lifted my spirits so many times. It’s not just singers like Kaushiki Chakravarty, Tina Charles but my chef heros like Julia Child and Manngchi, authors like Carol Shields, Julia Glass, Mahashweta Devi and Maitreyi Devi, fictional female leads like Ms Phryne Fisher and wonderful directors like Aparna Sen and The Wachowskis. These women have helped me focus on more important and productive things in my life and move on from things that do not require my time and attention. More importantly, like my closest women best friends, the above women have helped me laugh and be calm at times when I did not have much to look forward to.

Along with these women, fortunately, my work has provided me opportunities to observe strong women who are based in some of the poorest communities where most have never experienced necessities like clean water and hygienic sanitation. I have met some of the strongest women in these communities who inspite of everything, relentlessly pursue every avenue to keep their communities healthy and well informed. It is not the meagre salary that these front line health workers get for their job (ASHAs), but the tremendous respect that they obtain from their neighbors, peers and elders that keeps them going.

One of the greatest feminine strength is perhaps the capability to nurture and care. I have seen it amply not only in the women in my family and network, but also in the men in my life. The men in my family have always stood like pillars in support of every member. Many of my male teachers, supervisors and colleagues were extremely supportive to my growth and learning. On March 8th, the Director of the Institute where I work held a special tea meeting in commemoration of women colleagues. We were asked to speak on the moment when we felt empowered to be 21st century women in India. My reflections were that I have never faced a divide between man and woman while growing up, in my adulthood nor in my career up till now. I have never felt that I was denied anything because of my sex. Isn’t that empowering in itself? Maybe I am the fortunate few, but I wish my daughter and every daughter in India has the same experience too with their life.

The only real stumbling block is fear of failure. In cooking (like everything else in life) you’ve got to have a what-the-hell attitude. Life itself is the proper binge – Julia Child

 

Family based care

A friend called a couple of days ago, after a gap of several months, informing that her life has suddenly become very busy and unpredictable. A family member is terminally ill and so she is taking care of their child, in addition to her own. She is also rescheduling her work life along with her spouse, to actively care for the person who is suffering. As a result, she has no social life, along with cutting down on better growth opportunities at work… indefinitely. We may all plan our lives, but life’s learnings have other plans for us.

In spite of best hospitals and advanced medical care, we all have at some point of our lives cared for sick family members or relatives either for long term or short term or like my friend for an extended indefinite term. Unpaid contributions of family caregivers were valued at as much as US$450 billion in 2009 globally [1], and two thirds of these care givers were women with additional jobs outside home. Similarly, in India, the total unpaid contribution in health at home in 2010 by women was US$ 22 billion and by men US$ 5 billion (at a minimum wage rate). For the care seeker, family-based care is cheap, home based and in familiar surroundings. For the care giver, it will incur time management, resource mobilization (leaves at work, salary revisions) and sometimes (maybe often) mental hardship. But perhaps the biggest issue here is that no one tells, teaches or trains us of the right ways to take care of our own family members in times of need.

At a time when there is a definite shift in global disease profile from communicable (infectious diseases) to non- communicable diseases like diabetes, cancer or cardiovascular and injuries; family-based care can keep the healthy out of hospitals and those at risk out of sudden need of treatment (and sky high health expenses). Could family care be an integrated process just like sitting together and having tea in the family room in the evenings and politely reminding everyone of the daily medication schedules, quantity of medicine left for consumption in the house, doctor appointments, designated drivers or transport for the appointments etc? Could there be someone designated as the leader for providing this care within the family? How well would other family members accept this designated family health provider? Is there a possibility for this designated member to be trained in providing a first response to emergency care, identifying key symptoms, understanding when to reach out to a healthcare facility?

Both my maternal aunt and her husband were bedridden for long periods until their sad demise. My cousin took care of them, all alone though and it took its toll on him. But he had to learn a lot of ways through his life’s learning in palliative care- by observation, reading and talking to medical professionals within his community, to understand what was expected of him before he could chalk out a customized care system. I cannot say that anyone in my family of my parents, myself and my child is equipped at this moment to even identify symptoms that may lead to a near future health catastrophe at home, let alone what to do in case of an emergency. Like everything else in life, perhaps health of family members should not be left out to adhoc arrangements.

There are states in India where best practices, pilot projects and examples of successful family based care exist, however, unfortunately, health policies or even guidelines in primary healthcare systems omit this most important area of healthcare. If family and community-based healthcare is made stronger, and well connected with health facilities and medical practitioners, much of our health expenses could be reduced. In a country where the out of pocket expenses in healthcare are the highest in the world and families are pushed into poverty each day due to medical expenses, family-based care could perhaps help us in many ways. For one, knowing someone in the family is a designated care giver and formally trained (beyond google!) to respond during an emergency situation would help me sleep well!

[1] Ana Langer et.al. Women and Health: The key for sustainable development (2016). The Lancet Commissions, Vol386, September 19.

Neighborhood Engagement

The roads in my neighborhood are in a bad shape. For the last month, the municipality has been digging and filling and digging them again for revamping sanitation, kitchen gas and water pipelines. Working professionals in the neighborhood had to make alternate arrangements for transport since parking and plying cars was a great hassle (especially those with small children who had to get to school by 7:30am in the cold wintry mornings!). Small businesses such as vegetable, fish, fruit, houseware vendors bore the brunt too, as practically there was no movement through the neighborhood streets. There were no flyers or communication regarding what the municipal officials set out to do, how long it would take and how we could all cooperate. Hence, like many other decisions in the past, common citizens were once again expected to abide by adhoc policies and implementation procedures that someone somewhere may have designed, keeping the community in mind, but without minding to inform them.

Why do most government programmes fail? Why do citizens often associate well designed programmes with election gimmicks? Time and time again, I have seen the same in my work area of public health too. One big factor is the total closure of communication with beneficiaries -who ultimately define the success or failure of the entire programme!

Sometimes I wish we could borrow a few learnings from the marketing departments of commercial businesses. New products introduced in the market go through a rigorous process of research evidence, pilot testing, people engagement and proper canvassing. Although many a times these can be extended beyond reason for profit making, but without proper need assessment and participatory engagement, projects are on a downhill trajectory.

However, the present irritation in the neighborhoods has not been a bad experience so far. Through this process, I recognized a few neighbors with great potential in community engagement. A reclusive neighbor from the adjacent house came out with a flask containing tea, some paper tea cups and packets of cookies for the workers on our street. In India, daily wage earners mostly work in all construction/infrastructure projects. Men and women completing the physically challenging work of digging the dirty roads, could at least spend 5-10 minutes refreshing themselves with a hot cup of tea. Another neighbor led an active engagement with the workers. Asking them how long they would take, what utilities they were covering, and informing the neighborhood of the same. It was only through his information, that I could plan out my alternate transport schedule for the 4 weeks. One other proactive neighbor informed about the application forms for the new gas pipelines, without which, our house would have been surely left out from this initiative.

Although my neighborhood is covered in a mass of dust and people are constantly sneezing, coughing or both, and although we are on a make shift time plan, scampering around making last minute arrangements for keeping to our daily schedules, I am more or less happy to see that there are definitely some leaders in my neighborhood who act when the time comes with spontaneity and grace. While my contribution to the entire process may be limited to admiring them from my balcony and highlighting them on my minuscule blog or for voicing the lack of information at my neighborhood gossip sessions, the feeling of belonging to a community, of being part of a proactive neighborhood is motivating and cheerful.

A ‘Christmas’ moment

End of the year is not a very happy time for me. It brings with it the assessment of my ‘happy meter’ for the year gone by and in some year the meter is not really turning in a clockwise direction. This year things are a bit different, with a promise of new venture and new direction in the new year. Although there is no surety of these taking the happy meter in the right direction, but one can only hope for the best before starting on a new journey.

Today is Christmas, a festival I have always associated with peace and warmth. Like all festivals, it brings together family members connecting them physically or in spirit over long distances. The perfect Christmas moment for me today was when I sat down with my family to eat a hot breakfast in the morning. It was a very simple semolina porridge that I had made, with aroma and spices from my childhood spent in southern India (and a little help from YouTube). But the togetherness and warmth of sharing a meal was hugely satisfying.

At that moment, I also wished that each and every one of us experiences these simple happy moments. Irrespective of our needs, aspirations, lacunae in life, of facing life’s challenges alone, or with friends and family; deserve these tiny flashes of positive energy to help us tug forward.

This weekend I also watched a few mini series on Netflix. One of them was the British detective drama, Paranoid. I loved the character of Lucy, who had changed her life from one of self indulgence to self realization. I identified with her and the happy zone she was in and the process of change that she practiced. Life changing experiences help us grow towards a more inclusive environment. I haven’t yet understood the ‘present’ moment concept of Buddhism, as past is important to me, but I value the present moment, as each of these are opportunities to make a balanced choice, a balanced decision. Each present moment is a chance at moving towards a higher self, irrespective of the baggage of the past that we all carry with ourselves.

And hence, simple happy moments in life reinforce the power of hope. Tomorrow may not turn out to be as bright as today, but the day after holds the promise of being better than today, isn’t it?

Who knows how 2018 will shape up for each one of us, but as long as we all tug along on a path of hope and acknowledge each of these simple pleasures in life, our year wont be too bad, would it?

Merry Christmas, Season’s Greetings and Wishing everyone a brilliant year ahead!

 

Action through Participation

As a Research Administrator, my responsibilities include assisting faculty members make grant applications in Public Health research areas and coordinating capacity building workshops for early career researchers in grants writing and manuscript drafting. At one point in my career, it was but natural to pine for a deeper understanding of ‘field work’ to add value to the documents I would prepare. An opportunity to visit two ‘field sites’ to document successful best practices came through and I was happy to commit to them instantly. The first was to document record keeping by front line health workers in Eastern India. The second was to document health promotion in community settings in Western India. Both required engaging with health workers and community in equal measure. Both broadened my thinking and understanding beyond all the research papers and reports I had read.

One of the field site was a small dingy room without a window. About 30 women sat in the room, some mothers, some daughters, some newly weds and some with infants, all cheerful, oblivious to the dark interiors. A henna competition was on, to gauge whose henna bedecked palms were the best in terms of design and colour. Before prizes were announced, the women were asked to speak on what their dream was about their daughters. The henna competition had broken their inhibition and now they all spoke up. One woman said she wanted her daughter to be healthy, one said education and going to school was important, another spoke about financial independence. But they all spoke, and not about challenges they and their daughters face every day, not about the resource limited households they had to go back to, but about their dreams and aspirations for their next generation.

It was then that the Project Manager told the women about family planning methods, about how spacing between children was one way to keep both the mother and her children healthy, about discussing family planning options with their husbands and families and reaching out for resources and medical assistance in the nearby locality, in case they needed further advise.  What I was observing was a participatory action or engagement, where the community is an active lead for any intervention being planned for them. The Project Manager was part of a larger project involving community, private and public medical practitioners and health centers. He was not an MD or a PhD, but was highly skilled in community engagements. There was a level of comfort that he demonstrated especially while handling a taboo subject like family planning methods with women from a very conservative section of the society. Later on he told us that it was important for him to understand what the community wanted first, before he aligned it with what he wanted to tell them about his project.

Six months later, I had an opportunity of being involved with a group of researchers planning to conduct a study on immunization coverage in Eastern India through community intervention. The Intervention specialists, began with a question for the community. Once again the question was about their dreams and aspirations. As per their experience, for any community intervention to be sustainable, it was important to have the community participate in the study, not as a recipient, but equal in status as the researcher conducting the study. Most often, community interventions require social and behavior changes to have positive outcomes and this can be achieved when the community believes that there are substantial gains from the study which align perfectly with roadmaps to their dreams.

In one of our institutional projects on rain water harvesting and storage in several villages, it was seen that when the community participated as equals, there was substantial ownership. At the end of the project, when the research project team pulled out of the community, the residents took up a mechanism to pool in resources and maintain the structures built and the processes for water regulation, as a regular mechanism. The project was renamed as ‘Aapno Yojana’ meaning ‘our/my project’.

Additionally, cultural contexts are often overlooked while designing community interventions. In a country like India, where each region is different from the other, be it in language, religion, tradition, beliefs etc, one intervention will not be replicable in another setting. Participation from the community in devising intervention strategies not only provide ways to conduct the intervention, but also help drawing out indigenous solutions in resource sharing in resource limited countries.

Participatory Action Research can be valuable in sustainable community interventions. Some of the methods use a lot of listening and then devising an intervention plan along with the community. What is required is a strong monitoring and evaluation component to measure progress at every step. The cons include

  • Ethics- Both the researcher and the community have to believe that the intervention will benefit the community. While aligning the community’s goals with research objectives, there should not be a forcing on or manipulation to align research objectives leading to coercion.
  • Choosing community leaders- especially in projects where community is required to openly discuss topics that lead to behavior change, often a few representatives from the community are first addressed who then in turn become a relay team of informing others in the community regarding the intervention. Sometimes, these leaders can become quite dominating and forceful with their ideas and thoughts. In order to maintain balance, adequate monitoring and constant dialogue with the leading team and the community is required.
  • Not connecting with appropriate stakeholders- in addition to the community, the local health governance members have to be a part of the project. Once the project is completed, they would be required to continue to administer, monitor and guide the community.
  • No linkages with national/ state programmes/resource agencies- In order to be sustainable, the community intervention has to have linkages with ongoing national, state programmes. The project team should also be able to forge linkages with resource people who can be sought locally, like front line health workers, medical practitioners, hospitals, healthcare centers, diagnostic agencies and pharmacies. This would be valuable when the project is completed and the community still has people to reach out to.

In case of community interventions where participatory action cannot be utilized, appropriate ways to conduct research dissemination should be explored. Often research dissemination is done at a higher level, involving government functionaries, policy makers, research groups. The people who would benefit most, the community is not informed regarding the research results. Importantly, changes are being driven by some funding agencies who advise for strong dissemination components at proposal stage itself. Medical research involving drug and patient trial results are often not shared due to ethical factors. However, there are many public health research projects where dissemination mechanisms are not explored adequately. As a result, public health research is still conducted in silo and shut down in large cumbersome reports that are not accessible for wider reading.

A few interesting examples of participatory community interventions using different methods are-

  • The Maternal and Perinatal Death Surveillance and Response[1] project initiated by the Ministry of Health and Family Welfare in Bangladesh, which helped make substantial improvements in maternal death indicator. During open discussions with the community on maternal death at childbirth, the project team realized that excessive bleeding during delivery and delay in seeking appropriate medical care, delay in accessing appropriate transport to the nearest hospital, caused an increase in maternal deaths. Interventions were created to address these issues followed by policy level changes that led to better indicators.
  • Community Photovoice project[2], where community members took photos or wrote and spoke stories regarding barriers and promoters of eye care in rural India. Their voice identified a few key barriers such as alcoholism, unregulated blood sugar and hypertension. These can now be adequately addressed by strengthening the healthcare fabric within the locality.
  • Participatory Women’s group addressing maternal and child health[3]– front line health workers used participatory methods to prioritize neonatal and maternal health issues amongst a women’s group that in turn spread the information amongst women through implementation projects that they themselves assessed.
  • Developing smoke free homes in Kerala[4]– Pilot studies suggested that Community participatory action helped substantially reduce second hand smoking in homes. Interestingly, the study showed that husbands, who did not stop smoking on request of their wives, did so when the community together aimed at a ‘smoke free home’ drive.

It is also important for Public Health researchers to obtain information regarding various successful participatory action research methods that have been tried and tested.  A compilation of literature on various approaches to participatory action research is required. This would help researchers understand the implications of community participation and then to design intervention plans that have potential to be scaled up. Perhaps all the major funding agencies working with communities could come forward to collate information on their successful community intervention projects, at one place. Or perhaps scientific publication houses could bring out commissioned papers in this direction.

At a time when Public Health research funding is slumping across the world, it would benefit to test out different methods of participatory action that have scalability and sustainability while being minimally resource intensive. In developing countries where population numbers are high, people are the true strength and the only resource. Bringing them together, learning from them and linking them to the local resources available should be the primary objective of the researcher involved in designing community interventions. Participatory Action Research can help bridge the gap between people and the Sustainable Development Goals we have set for ourselves to a great degree. As researchers, we have to merely facilitate this connection.

 

[1] Biswas, A., Rahman, F., Eriksson, C. and Dalal, K. (2014) Community Notification of Maternal, Neonatal

Deaths and Still Births in Maternal and Neonatal Death Review (MNDR) System: Experiences in Bangladesh. Health, 6,

2218-2226. http://dx.doi.org/10.4236/health.2014.616257

[2] Rani PK. et. al. (2017) Envisioning eye care from a rural perspective: A photovoice project from India. Int.Q.Community Health Educ. doi: 10.1177/0272684X17736153

[3] Tripathy, P. et. al. (2016) Effect of participatory women’s groups facilitated by ASHAs on birth outcomes in rural eastern India: a cluster-randomised controlled trial. The Lancet Global Health, Vol 4, No.2, e119-128. DOI: http://dx.doi.org/10.1016/S2214-109X(15)00287-9

[4] Nichter M. et.al. (2015) Developing a smoke free homes initiative in Kerala, India. BMC Public Health. 15:480. doi:  10.1186/s12889-015-1815-1