Mother’s day- How do we save our mothers?

We have recently celebrated the woman who has helped us cope with life not only during our childhood, but also adulthood. We showed our appreciation to the superwoman, who shields us from everything that could cause us pain, and sometimes, to our embarrassment and sometimes joy, tries to guard us even when we are supposed to have found our own footing in the big world outside home. She is universally revered across cultures, religions, countries or the n number of divisions we have made to segregate ourselves.

But something isn’t right. Why are our mothers dying and why haven’t we been able to curtail this, even in 2017?  Maternal death is a serious issue especially in developing countries. Although we have brought down global maternal mortality by 47% since the 90s, as per the World Health Organization (WHO), about 830 women die due to pregnancy/delivery related problems around the world each day. These are mostly preventable. 99% of these deaths occur in the developing countries.  The odds of a 15 year old dying due to pregnancy/delivery related issue in developed countries is 1 in 4,990. In the developing nations, it is 1 in 180. Sadly most of these deaths occur due to reasons that are within our control.

Severe blood loss during pregnancy and post delivery is the main reason, followed closely by infections. In most cases of severe hemorrhage, injections of Oxytocin are enough to slow down blood loss. The many reasons for maternal death are health inequities, aka, basic services are not available to those who cannot pay for care. Distance to the nearest health care facility, availability of medicines in the facility, inadequate services are also key reasons adding up to the issue. A UNICEF led project in 6 states in India based on verbal autopsy of family members and community members of mothers who had lost their lives during child delivery, showed that cost for transport to the nearest health facility, literacy level of the mother, community awareness were leading cause of maternal deaths.

Personally I find the lack of awareness and non adherence to hygienic practices during childbirth and subsequent death of mothers due to infections, is most unsettling. Sepsis is a major problem, both in maternal as well as neonatal death. These defy all norms for extent of negligence. Additionally, through our incessant use of antibiotics we have successfully created microbes which are now resistant to most drugs, hence can easily compromise an infected mother and her newborn.

The WHO has recently adopted a resolution on sepsis that urges member nations to be more cognizant regarding causes, prevention and treatment of sepsis and tighten policies and regulations of activities leading to Antimicrobial resistance (AMR), to develop AMR stewardship activities and strengthen hygienic practices, clean childbirth practices and improvement in sanitation and nutrition.

Some of the basic things that we could do at our levels would be to create awareness amongst everyone we come in contact with. Every time we visit a clinic or a hospital, we could inquire about guidelines followed in infection management, waste management and AMR. We could also remind the health practitioners about hand hygiene and seek their advice in ways to prevent infections at our homes.

Every family needs a mother and every mother deserves a good healthy life, especially one that can be met by a few prevention steps

 

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Summer or Simmer!

It is hot in my city, absolutely scorching and I miss my walks through the office garden. I feel my skin burn everytime I have to be in the open and the tap waters are perpetually hot, be it early morning or late evening. This dry kind of heat penetrates my soul and dehydrates it to the core. I am snappy and irritating to be around and always dreaming of ice creams and popsicles, so yes, when I am in office meetings, I am really not listening, my notes are usually full of doodles of ice cream cones and faces transform to chocolaty glaciers. I am not used to extreme temperatures and every summer, I suffer a heat stroke. My family members have gently advised me that it’s only a state of mind; that I need to shut myself off to the surrounding heat. Is that really possible? Would imagining myself in an igloo solve the problem? I don’t think so. The constant ice cream images dont help either.

And I am humbled by everyone who has to work outdoors during this peak heat, especially those indulging in physical labor. Yesterday, my daughter’s homework (she is in grade III) was on interviewing the person who cooks at home and find out their struggles and how she could support them in their work.

I had tried pushing myself as the cook at home, as a potential interviewee, which she quickly ‘shooed’ away as ‘you are not the official cook, only the weekender experimenter’ and I clearly heard the Thank God! in her expressions that the household did not have to bear my recipes during most of the week. Instead she interviewed Manju who makes dinner for us at home every night. Manju is the representative of a quintessential Indian support system for working mothers like me. I am only blessed to give her full independence of my kitchen on weekdays, so that I don’t have another ‘to do’ item on my never ending list. And gratefully, my daughter likes Manju’s culinary skills, so I am fine with it too.

Manju was very amused with my daugther’s questions and it came as no surprise that her main struggle was to tolerate the kitchen heat, the hot stoves in the several households she sustains with the food she makes everyday. As to the support she requires from my daughter, it was a measly glass of cold drinking water after her chore at our home. Even though Manju and I share ups and downs in our otherwise healthy relationship, my appreciation and respect for her and for all those champion support system reps like her, did increase after yesterday. It also helped my daughter be more cognizant about everyone around. Though she is a better and far more empathetic person than I am and I hope this trait stays with her as she grows older.

As a public health research enthusiast, I am glad that several cities have a ‘heat action plan’ this year and are attempting to generate awareness amongst community on ways to beat the heat, in addition to capacity build care givers on responding to heat related illness.

Temperature tolerating clothing based on chemical and electrical principals is also in the market. These can bear extreme temperature shifts and are suitable both for cold and hot weather. Some of these are being tested in soldiers who are posted at extreme weather conditions. I look forward to a day when cheaper versions can be worn by construction workers, road repair men, community care givers and the Manjus at every home. Here’s to innovations for community health and to a safe summer everyone!

Ship of Theseus

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If a ship is replaced part by part up to a point where not a single original part remains in it, is it still the same ship?

This is a central theme of the philosophical paradox and has been reflected in the 2012 movie of the same name (which I happened to watch yesterday….yes I know, I am late by a mere 5 years!). The film depicts the journey of three people who have had an organ transplantation, cornea, liver and kidney respectively. I wish the filmmaker would have delved a bit more on how the transplantation changed the recipients. Especially since the corneal transplant was done on a blind woman who was a talented photographer and would rely on sounds to capture pictures, before the surgery. After the surgery, I wonder if there was a difference on how she would perceive photography, now that she had both sight and sound to rely on.

But on a deeper level, we have all gone through periods of breaking down, learning and then moving on in life. At each of these ‘episodes’ we have given up a part of ourselves as in our beliefs, and gained some qualities to face life, become stronger. So even if we may not remain our ‘original’ factory setting self, the constant learning, re-learning has made us the person we are. Hence, by the Theseus paradox, we may not be how we started, but we are still our own unique self.

I believe that life’s constant motion of shaping our thoughts takes us on our path to spiritualism and our higher selves; however, we have made a mess of everything with soul, re birth, immortality etc. in this mix.  It would be simpler to just focus on the process of creating and re creating ourselves and getting through life, while being ethical with our surroundings.

However, ethics for me can be different from for instance, the monk in the film, who would walk miles and miles without footwear so that he doesn’t hurt insects on his path. A part of the monk did change though, as he was shown advocating against using animals in research at the beginning of his story and finally made peace and went through a liver transplant and medication regime, to survive liver cirrhosis. Both transplant technology and pharmaceutical industry use research on animals at some point in their development, and that was something the monk had to come to terms with.

It’s very difficult to go through the metamorphosis of having our principles crumble and regain our strengths, but that is exactly what makes life interesting as well. And perhaps we should not tag it with whether it was the right thing to do or wrong, since it was for that moment in our lives, we chose the best thing for ourselves.

One health- isn’t it a bit late for that?

While discussing a school assignment on different birds with my second grader, we watched videos of humming bird drawing out honey from flowers and weaver birds weaving artful nests. I also told her about the first time I had seen green pigeons. A pair of these green birds had made a nest close to my window and I had watched over them for a couple of months, till two young little birds were added on their family and then the four had flown away together… on their onward journey. There is something satisfying in bird watching and the way they conduct themselves. Unlike any other member of the animal kingdom, birds are perhaps the most sober and dignified and sometimes great entertainment!

The assignment also had a question regarding which birds had her parents seen when they were young and were rarely seen nowadays. When I was growing up in my grandmother’s house, we were often surrounded by sparrows and sometimes a couple of cawing crows. I don’t see sparrows anymore, especially in the cities I have lived as an adult. I tried finding some data on sparrows, unfortunately there is not a lot of research done on them. Their numbers are low and the ones who made it have migrated to greener, less polluted suburbs and villages. Two things caught my eye in the past week. The term ‘one health’ which really means to have everyone who deals with human, animal and environment health on one platform. Since 60% of diseases in man have some sort of origin in animals and since in turn, man has contributed to effectively denude the environment off more than 60% of its resources, now man has decided that we should all work together if we are to save ourselves from animals and the depleting environment. This is the big health jargon of 2017 that will be used over and over on all research applications, debates and talks this year and perhaps till we move on to something more ‘in’.

The CDC page on One Health, mentions “One health recognizes that the health of people is connected to the health of animals and the environment (www.cdc.gov/onehealth/)”. Isn’t it funny that it took us till 2017 to recognize that our health is connected to other beings around us? The real reason is perhaps that as researchers, we have all built our silos of working with our own folks with our own perceptions, like a medical professional may not be seen as a talented basic researcher, a  PhD is seen to be focused only on their bench work and not understand diseases, and veterinarians, well they have been completely dismissed from participating in any ‘serious research’ related platforms. As researchers, we have let our insecurities and sometimes dire selfishness keep us from sharing our results, collaborating and even talking openly about our interesting findings. When we cannot build bridges across our own fraternity, how will we come together on an unified ‘one health’ platform and work together to better our environment?

And why veterinarians alone? We should also partner with anthropologists who learn from living with communities who are closer to nature. The indigenous tribesmen of any country have been practicing living in harmony with nature for as long as the human civilization. We should perhaps seek our ‘one health’ answers from them.

The other item that I found interesting was that telomeres seem to grow longer in space. Isn’t it interesting that telomere which dictate ageing in an individual, grow longer in space? Was the incident a one off, or was it due to space being untouched by pollution, untouched by man as yet? Anyways, since we haven’t been able to find another earth to call our home yet, we should like our own spiritual growth, ‘look inwards’.

Would one health change our perceptions about working with each other for a better world?….only time will tell. Till then, I hope someone somewhere works on sparrows and  brings them back to my neighborhood!

 

 

Intergenerational transmission of poverty and escaping the poverty trap

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Last weekend I watched a delightful movie on something quite close to my heart. ‘Nil Battey Sannata’ depicted a mother and daughter’s journey through life. There were several moments which I could totally identify with. It was superb acting by a very able cast and although the subject was very down to earth, of a mother’s trials to provide a good future for her daughter, the cinema did do justice to balance all emotions very well. The teenage daughter had already resigned to the fact that her mother wouldn’t be able to put her through an expensive higher education, and had gone ahead and explored options of choosing a career as a nanny, something within her realms and ability.

A few days ago I was involved in a project dealing with intergenerational transmission of poverty and some of the dialogues in the movie brought back thoughts from work. The mother depicted in the movie was a daily wage earner, working in the informal sector. In India and many other lower and middle income countries, there is a huge section of population working in the informal sector and most survive on day to day earnings. Some don’t have enough to meet their daily needs and most do not have anything to save for the future. And this brings in another worry of a huge population of elderly people resulting from the same informal sector, without any sort of retirement savings.

I strongly feel that every human has a right to dream a rosy future and somewhere when one is consumed with thoughts solely of how they/their family can survive the next day, life is not completely justified. There is some information from research and mostly from the field of economics that intergenerational poverty is transmitted from parent to children especially in those living below the poverty line (BPL). Somewhere, there is a little mismatch, since the huge middle class strata of India, which extends from those just above the poverty line to those doing very well, often times demonstrate examples of children capable of attaining their dreams through hard work and education loans and scholarships and being able to climb from one strata to that higher. This is somehow extremely difficult for the poorest of the poor (BPL), even though many of the schools have very similar opportunities for growth. Additional aspects such as health and nutrition have been implied to add to lower school attendance in children and the reasons for being unable to escape the poverty trap become complex with multiple compounding factors.

What has been seen to work to some extent is conditional cash transfers (CCT). And more evidence from research is needed in this area. Pilot projects where cash transfers were made to the BPL families, tagged with compulsory school attendance, or availing government immunization/health programmes were seen to effect family nutrition and quality of life in a positive manner. School attendance also improved due to better nutrition and health. This would probably be a mechanism to escape the poverty trap. However, much more needs to be done in a proper structured manner. Also the process for CCT needs to be efficient without involving too many intermediaries that can raise avenues for corruption or bureaucracy or both (one stop mobile money transfer has worked well in Kenya). Community cooperatives also work to some extent, however, a strong community engagement, community participatory action methods are needed to be explored.

I am often frustrated that researchers do not come together to build sustainable projects. Grants are mostly driven with motivation for a few publications, or a PhD degree or obtaining a faculty position. Sustainable projects can be made possible only by a multidisciplinary team and until researchers stop working in silos where an economist only works with another economist and a qualitative researcher only with their own folks, it will be very difficult to achieve anything meaningful on the ground. One can generate multiple models of why things are not working, but ground level realities require tangible practical solutions and most importantly, ones which are sustainable in minimum resource settings.

Picture acknowledgement- Asian Development Bank

Anja and Hope

We are surrounded by it. No matter what steps we have taken, nationally, internationally, through government or through not for profit sectors, there has been no escape from it, nor will be for the next decade to come. Poverty will remain, so will the hunger in the emaciated bellies and eyes of little children and mothers will continue to weep, watching their conditions or abandon them out of sheer desperation and frustration of not being able to keep their promise to the little ones.

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This picture is of a two year old Nigerian boy, abandoned by his family and of Anja Loven, a care worker. I am sure her profession would have presented her with many similar occasions to come in contact with undernourished and emaciated children. However, something about this particular boy was different. It’s the sixth sense we all have, of knowing that with a little care, sometimes, the cycle of life can be reversed.

Anja named him Hope, and she and her colleagues took care of the boy, sent him to a medical facility and helped him heal. Today Hope is better. One cannot distinguish him from other children his age (Pic 2).  It just took proper medical care and kind attention to reverse the child’s state within months. Anja’s plea over internet also allowed for 1 million USD in donations to take care of Hope’s expensive medical bills.

Instead of asking why there’s not enough being done for the many other little ones who need all our support, I would state that this beautiful story shows that one person can make a difference in one more person’s life. That’s all it takes. We don’t have to save the world, we can leave that to the others. What we can do is to help just one more life. Be it a human, a bird, a tree or an animal.

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We do not have to provide monetary assistance always. A few students at my friend’s university campus got together to teach children of lesser salaried staff, during their free time. All it takes is time and a will to do something. The important thing is to make the effort. I am encouraged to see that the next generation of youngsters are immensely motivated and creative and moreover aware of their environment. They can design what’s best for the future of our country.

If we really cannot do much by ourselves, we should at least try and encourage those who are making a difference.

 

 

Of Mental Wellbeing

“Your job is not to judge.

Your job is not to figure out if someone deserves something.

Your job is to lift the fallen, to restore the broken,

And to heal the hurting.”

-Joel Osteen

I remember a college trip to Srisailam waterfalls. The monsoons had just passed and our group of jolly youngsters was greeted by the gorgeous, abundant gurgling falls. But perhaps what is etched in our memories even today, is a group of patients from a local mental health rehabilitation center, mostly elderly women, all squatting together, their legs chained and bound firmly, as though they would just spread their arms and fly, if freed. Their condition stopped us in our tracks. We could not appreciate the natural wealth posing a distorted, contrasting picture behind the queue of suffering, helpless people in need and most importantly, a humane understanding.

I hope that we have come a long way from those days; however, I am certain that there is a longer way to proceed before we even start to manage mental well-being in our households, in our community; and understand the differences in the wide spectrum that constitutes mental health.

A review of the national report on Accidental Deaths and Suicides in India 2014 http://www.ncrb.gov.in/ shows that 17% of suicides in the world occur in India. The biggest cause of suicide is illness and prolonged illness (aka health related issues). Probable reasons being, medical expenses, hospital expenses, lack of proper hospice care, societal/family alienation, compounded with physical inability at meeting basic day to day self care needs. How immensely sad it is for all of us that our own who are already suffering due to physical illnesses have to additionally undergo insurmountable mental stress.

A country of 1.25 billion people, of whom 83% are mentally and physically strong enough not to commit suicide, cannot take care of 17% of population who cross the bridge and push themselves to end their lives.

The World Mental Health Day will be celebrated on October 10. India has slowly begun to acknowledge that mental health as a key to wellbeing. We are slowly understanding the differences in mental health, mental health conditions, disorders and how these can be treated and overcome. We are also arriving at the knowing that a positive environment can build a positive life. Our schools and our offices are encouraging mental wellness programmes.  However, our homes, our communities are not doing enough. ‘Mental health begins with me’ is aptly the first mantra to mental wellness. Though unlike physical discomfort, which is easily sensed by an individual, mental discomfort is seldom acknowledged by our own self. Although with a strong family, community and social network, this can be easily identified and alleviated at very initial stages.

Families are the first line of social network and it is easy to identify sudden changes in behavior of family members. The key is to invest time in building an open communication channel with family members. In our race to meet deadlines, to showcase ourselves in the eyes of those we think are important, we turn our back on our most important allies, our silent supporters, our parents and our children. There is great power in observation, but we must give our own that much time and commitment.

Additionally the stigma attached to the word ‘mental’ deters even acknowledging that there may be issues amongst family members. Is our social status of being a ‘perfect family’ so important that it overrides our intelligence in disregarding obvious changes in behavior and attitude which can lead to a far greater problem for our loved ones leading to irreversible changes in our lives? Coping with suicide death of a family member is an even greater challenge.

Fortunately, there is help. Several not for profit organizations are diligently involved in community awareness programmes (listed at the end along with other resources). Representatives are trained in identifying symptoms and more importantly, to discuss with members of a locality on how to identify signs and symptoms of mental distress in their families and providing the first line of care. If you live in a society housing complex, you could ask the managing officials to call the NGO representatives to deliver lectures. If you live in an independent house, you could request lectures through your local clubs. It is also important to get everyone to these meetings, including those who support our households on all levels and belong to every economic background.

Equally important is to be vigilant and empathic to those we interact with on a daily basis who are outside of our family. Sometimes, it helps to be a patient listener with the local grocer, the domestic help or even the lucky neighbor whom you get to see only on weekends. Going by success stories from all other public health areas in both research and implementation, it will be actions taken at the community level, by the community that would be sustainable in the long run. No external resource, aid, or team can bring about a substantial prolonged difference, unless we at individual level are aware and accountable for our own and those around us.

The Mental Health Care Bill that was passed in the Rajya Sabha recently, demonstrates the initial shift in our mind set by acknowledging attempted suicide as caused by extreme stress and disassociating it from being a criminal offence. The government and not for profit sectors can help us capacity build a manpower trained to facilitate mental health awareness at a household level. Our capable and ever smiling front line health workers (ASHAs and ANMs) are often burdened with multiple responsibilities, compounded with a measly incentivization process. While we strengthen our communities, national and international resources could be channeled to create a stronger health system management process by training a large team of health workers who are motivated to put in their efforts. A large trained mentally happy workforce can care for a larger population needing good quality care and service.

That mental wellness is a key to overall good health is evident from the scriptures that helped us grow through ages. The past does hold solutions to our future. How else would have Arjuna won the battle against the Kauravas, without the constant mental support provided by his most experienced charioteer?

Reads:

http://www.apd-india.org/?q=what-we-do/healthcare/community-mental-health-program

http://www.scarfindia.org/community-mental-health/

http://manas.org.in/default.aspx

http://www.thebanyan.org/html/communitymental.html

http://www.sangath.com/index.php

http://www.anjalimentalhealth.org/about.php

http://mhfkolkata.com/index.php/our-services/psychiatric

http://www.aasra.info

http://www.suicide.org/hotlines/international/india-suicide-hotlines.html

http://thelivelovelaughfoundation.org/