case study g

Swasthya: The Politics of Women’s Health in Rural South India

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The Practice of International Health: A Case- Based Orientation Daniel Perlman and Ananya Roy

Print publication date: 2009 Print ISBN-13: 9780195310276 Published to Oxford Scholarship Online: September 2009 DOI: 10.1093/acprof:oso/9780195310276.001.0001

Swasthya: The Politics of Women’s Health in Rural South India Suneeta Krishnan

DOI:10.1093/acprof:oso/9780195310276.003.07

Abstract and Keywords This chapter looks at experiences providing health care to rural women in India. It shares thoughts about the quality of health care offered to women. The chapter also describes the establishment of the Well Woman Clinics, aimed at providing empathic reproductive health care, including information, counseling, and clinical services to women. Community health workers (CHWs) were trained to take a comprehensive, broadly defined health history and provide pre- examination counseling to help women assess what kind of clinical consultation they required and become acquainted with routine examinations.

Keywords:   health services, reproductive health care, women's health, rural health, public health practice, health workers

In August 1997, three American students, including two of Indian origin, met at a newly opened cyber café in Bangalore city, India, to plan a women’s health program in Vijaygiri,i a rural community 350 kilometers away. Rajiv, whose brainchild the program was and who had raised funds for it, did not turn up for the meeting. The others decided to go ahead with their trip to Vijaygiri anyway. So, at the height of the monsoon season, the trio traveled to Vijaygiri to conduct a needs assessment for the program. I heard of their plans through a friend. In search of inspiration for my dissertation research, I decided to tag along. My father had passed away recently, and the sudden loss had left me drifting. I needed to find an anchor, a focus.

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At around 9 P.M., we boarded a “luxury” government bus that turned out to be anything but luxurious. Last-minute booking meant that we had the last row. After a few hours on a relatively straight highway, we started to climb up through the mountains. In the last row, even the most minor pothole tossed us high off our seats. And the rain! The rain came pouring down the whole night, leaking through the cracks around the edges of the windows. The next morning I stepped off the bus at the Vijaygiri bus stand damp and aching.

The bus stand was a patch of ground big enough to accommodate two buses and a few auto rickshaws. Coconut, arecanut, and other trees bordered the stand and houses crowded in on the sides. It was about 5 o’clock in the morning. Faint strains of the traditional Sanskrit morning chants played on a radio. A few auto drivers were standing around, yawning and stretching. Now that the rain had ended, the air was crisp, cold, and damp. Leaves on the trees were fresh with dew and (p.129) rain. Ah, how peaceful, how idyllic were those first few moments in Vijaygiri after the hustle and bustle of Bangalore. “Perhaps here I will find a dissertation topic and peace after the turmoil of my father’s death,” I thought.

No one was there to meet us, so we approached an auto rickshaw driver and asked to be taken to the hospital. We drove through what looked like the main road of the town, up a hill and around a corner. There at the top of the hill was a sprawling pink building. To the left, by the side of the parking area, was a badminton court. People slowly moved about with toothburshes, towels, and flasks. No one seemed to notice us. We wandered in through the main entrance and reached an inner courtyard with hallways going left and right and stairs going down. Just as I began to feel a bit frustrated, we saw a tall man, maybe in his fifties, walking toward us from the corridor on the left. He carried himself with an air of authority, but at the same time his smile was open, welcoming. He reminded me a bit of my grandfather. It was Dr. Vasan, the chief medical officer of the hospital.

Rajiv and the students I was with had worked out the broad goals of the project with Dr. Vasan. The idea was to extend the mobile clinics that the hospital was conducting to make outreach more regular and to recruit a group of local women to engage in health education. The initial mission was to “empower women with information and other tools to make and act upon health care decisions.” I was wary of the fact that the project did not have an explicit ideological or theoretical orientation. Further, there had been no discussion about roles and responsibilities—of the student group, the hospital, or the health workers we would recruit. I was apprehensive that the undertaking might turn out to be a haphazard student project rather than a formal program and about being saddled with responsibilities that I had not had time to fully comprehend. I was already a year into my “all but dissertation” status in the doctoral program in epidemiology at the University of California, Berkeley, and was conscious of

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the need to stay focused on completing the dissertation. I was also committed to a project that would keep me linked to my childhood roots in India—a desire that had shaped the focus of my undergraduate and graduate studies in the United States. Thus, quite quickly, I became the group’s point person.

Later that first morning, after we had showered and dressed, we met Dr. Vasan at the canteen, a low-roofed annex to the main hospital building. As we devoured the iddlis (steamed rice cakes), chutney, and sweet hot coffee served in 2-inch- high steel cups, a doctor who looked to be in his early thirties greeted Dr. Vasan with respect and then turned to us with an excited smile.

“So these are the Americans.”

“This is Jagan,” introduced Dr. Vasan. “He has been running the hospitals’s nursing program and the community outreach.”

Dr. Jagan seemed excited and enthusiastic about meeting people interested in his line of work. We began to discuss what our role at the hospital would be, and once our conversation was under way, Dr. Vasan excused himself to begin morning rounds and left us to our discussions with Jagan.

(p.130) A few days later, in an airy, spacious office of the hospital, I met with Dr. Jagan and the honorary secretary of the hospital, an elderly, sprightly man who had retired from the banking sector. Jagan seemed far more relaxed in the presence of the secretary than in that of Dr. Vasan. In fact, he was in his element.

“What we need is mass education,” he announced. “Now is the time to start. I have 20 girls finishing the nursing course this month.” Dr. Jagan had been running a 1-year training program for nursing assistants, who were simply called nurses. If we did not move fast, we would lose the opportunity to recruit a few of the graduates. Most got hired by nursing homes and clinics in the district and neighboring districts. Once they got jobs, it would be difficult to recruit them for our project. And once we hired them, we would need to initiate training as well.

At first I was reluctant to rush to action, hoping instead to take our time in developing a solid plan. However, I caved in.

“We’ll interview the candidates tomorrow,” announced Dr. Jagan.

The secretary seconded the proposal. Dr. Jagan recognized the importance of identifying young women with a commitment to staying back in their home communities, with an interest in working on women’s health. But I learned from him that in order to accomplish our goals, we had to work very strategically

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In her more recent work, Suneeta Krishnan has been operating out of urban clinics in Bangalore, India, interviewing young women about their marriages, economic situation, and sex lives. (Photo: Jason Taylor for Time.)

within the hospital. We had to bring on board the authorities, like the secretary, and the staff, like the head nurse, by trying to work on terms acceptable to them.

On one of my early trips, I drove back to Bangalore with Dr. Vasan and his wife, Dr. Sarojini. Dr. Vasan was in a nostalgic mood and eager to confide. We spoke

(p.131) at length about the hospital during our ride to Bangalore—about the 10 years they had spent struggling to establish the hospital, and about Dr. Jagan. I learned that Jagan was a native of the town, trained in Ayurvedic medicine. “We sent him to get training in anesthesia. The main problem with him is that he doesn’t have confidence. He doesn’t focus,” Dr Vasan said.

“You know, for even a little thing, he will send people for an x-ray, an electrocardiogram,” added Dr. Sarojini.

Dr. Vasan continued in a resigned voice, “I manage with him. His main strength is public relations. He will be good at helping you with the training of these health workers and talking to the panchayat [village council].ii He’s good at handling politics. But I will come to the weekly clinics myself.”

In contrast with what Dr. Vasan had told me, Dr. Jagan seemed very confident. As the project evolved, the student group and the community health workers (CHWs) relied on him to negotiate with the hospital authorities as well as with local village authorities like the panchayats and local landlords. He had the ability to connect with people and to speak in ways that they could identify with. I felt that ultimately it was Dr. Jagan who understood the project—and in many ways it was his project: it emerged as an extension of his nursing training program and his community outreach work. For years, before Dr. Vasan and Dr. Sarojini had joined the hospital, Jagan would hitch rides with taxis and jeeps going out to the villages to offer health care and information. He had a strong commitment to social service, which made him a natural leader for our project.

Our new recruits, the CHWs, participated in a 3-month training program in community health. During this time, Jagan lobbied with wealthy families and local panchayats to donate space for the CHWs’ health centers. In January 1998, we launched health centers in six villages within a 30 kilometer radius of

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Vijaygiri. Jagan and Dr. Vasan planned a grand launch—a large multispecialty camp. Camps are a common strategy used in India to promote health-care access as well as utilization of particular kinds of health services such as sterilization or screening. A number of doctors we met at Vijaygiri and Bangalore who were involved in community health all felt that the most effective ways of establishing oneself in the community was by providing basic medical care through camps and outreach clinics. Dr. Vasan and Jagan too felt that this was crucial.

The day of the launch, Jagan was extremely tense but in charge. He paced up and down, checklist in hand, overseeing the packing of equipment and materials. We left the hospital as a convoy of four vehicles. The hospital van left at around 8:45 A.M. with a team of student nurses, laboratory technicians, and equipment. Jagan followed in his car with the CHWs, his wife Ila, his daughter Ashwini, and Ashwini’s puppy Amitabh, named after a famous Bollywood actor. I followed in a jeep with Dr. Vasan and a few other doctors.

The first center, located in hilly estate country, was being launched at the village farthest away from the hospital. It consisted of two rooms within the village government office at the foot of a hill. Areca nut trees dripping with black pepper (p.132) vines and sweet-smelling coffee bushes in bloom grew on the slopes. Closer to the summit were the neatly cropped tea plantations.

By the time we reached the site at about 10 A.M., at least 50 people had gathered. The majority were women, some with children. The panchayat officials, registers and pens in hand, seemed extremely organized, as did several community volunteers. There must have been a team of about 20 organizers and a total of about 8 clinical specialists at the camp. It was 10:15, and a festive atmosphere prevailed. Hindi pop music blared on the speakers. The panchayat officials decided it was time to begin.

The next thing I knew, the owner of a local tea estate who was sponsoring the day’s program was announcing my name, and I was led to the stage by one of the camp volunteers.

With a dry mouth and a racing heart I walked to the microphone. Over 100 people had gathered by then. Dr. Jagan introduced me: “Now, Mrs. Suneeta Krishnan will say a few words about Swasthya. She is one of the dedicated students who has come all the way from America to work with us.”

I reminded myself that I was the “laudable American” and could do no wrong. Braced by this thought, I launched into my speech, in English: “Today’s program is a true representation of what Swasthya is trying to accomplish: local communities, the hospital, and the Swasthya team working together to promote health. We hope this partnership will be a long and successful one.”

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Dr. Jagan stepped up to translate and then launched into a few of his own remarks: “Our goal is to provide not merely treatment but also health education. Illness prevention is the goal.” Throughout the life of the project, he would repeatedly emphasize this goal.

Finally, after what seemed to be an eternity, the speeches came to a close. The panchayat president (head of the village government) kicked off the camp by requesting all those who wanted a health checkup to register. In minutes, a long queue of men, women, and children formed at the registration desk in front of the panchayat office. Three young men, panchayat volunteers, sat at the registration desk and asked each individual to identify which specialists he or she wanted to consult. I watched the proceedings for a few minutes. There were many women in line—dressed in their holiday finest, with flowers in their hair and colorful glass bangles on their arms. Some had babies on their hips. A few were chatting and joking; others looked tense.

“Do you live here—in this village? It looks like the entire village is here!” I asked a group of women in broken Kannada, the local language, peppered with Tamil and Malayalam, the two languages that I spoke growing up in Kerala, another South Indian state.

“No, we are from the tea estates up over the hill behind you. We had to walk nearly 8 kilometers to get here,” they replied. Behind me was a steep hill, crowded with tall, lanky silver oak trees whose leaves glistened like silver in the sun. The district had many large estates tucked away at the tops of remote hills. Some provided (p.133) basic primary health care, but in general accessing care was a considerable challenge, given the terrain and the distances involved.

I was with another Indian-American student, Preeti, who was taking about 6 months off before starting medical school in the United States. For us, this first camp was an opportunity to begin understanding the range of health problems that women had, how they talked about them, what they did, and how local clinicians responded. We decided to split up, observe, and take notes.

I continued to stand by the registration desk to observe the requests being made. Once the women realized that I could speak a little Kannada, they started to talk.

“My two children and I walked 10 kilometers across the paddy fields over there,” a woman told me, pointing to the valley down below the panchayat office. Green fields beginning to turn a golden brown, approaching the winter harvest, extended for several kilometers ahead. Near the horizon I could make out a settlement. At the camp, we learned how important the local terrain was in shaping women’s access to care. This region is heavily forested and mountainous. Many villages are tucked into the hillsides and surrounded by dense vegetation. Because of heavy rainfall, there is extensive paddy cultivation

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in the valleys where “villages,” consisting often of just a handful of homes, are separated by kilometers of fields. Distance and lack of transportation were therefore important barriers to health-care access.

“We even missed a day’s pay to come to the camp! Management is like that— they won’t even give us a day off if we are sick,” said one young woman.

“Sixty kilos we pluck. Is it any wonder that we have back pain and white discharge?!” questioned another.

Many of the large estates are mandated by law to provide basic amenities such as health care and primary education. However, most of these clinics are run by male doctors. Doctors and women are uncomfortable with physical exams; therefore, if a woman does seek care for a gynecological problem (which she may not), treatment is usually based only on reported symptoms. Without the estate doctor’s permission, women would incur leave without pay if they needed a day off to seek gynecological care from a woman doctor, who might be anywhere from 10 to 30 kilometers away.

One woman explained, “When we to go to the town to see a lady doctor, we have to spend so much—5 rupees bus charge and another 50 rupees to the doctor. And then the medicines.”

Even when health care was accessible, as in the case of our camp, the culture of silence around women’s gynecological health was so pervasive that women would not reveal their problems. The fact that we were requiring everyone to publicly state which specialist they wanted to see was clearly not conducive to making women comfortable about indicating gynecological concerns. Further, we had young men sitting at the registration desk noting down this information. This did not strike me immediately. But as I stood there for 5, 10, 15 minutes and found that so (p.134) few of the women were stating gynecological problems and seeking consultations with the gynecologist, I began to become suspicious.

My uneasiness was confirmed when I struck up a conversation with a tall, thin woman who looked to be in her thirties. She seemed tense and apprehensive, wringing the edge of her sari, scanning the crowd. I approached her with a smile and welcomed her to the inauguration of our new health center.

Bharati was her name. I described Swasthya’s services and focus on women and I asked her what concerns brought her to the camp.

“Headaches,” she said.

“Have you been having any other problems?” I asked as we waited for her turn to register.

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“No,” she said uncertainly. Given her hesitation, I engaged her in some lighter conversation. “So, how many children do you have?”

“Three—two girls and a boy.”

“Have you brought them also for a checkup, or did you come on your own?”

“I came on my own.”

“So tell me, how is your health? What kinds of problems do you have?”

She moved closer to me, and while keeping her eyes downcast, confided, “I have been bleeding a lot, more than what is my usual, and throughout the month.”

I asked how long it had been happening.

“It’s been more than half a year now. But the estate doctor said not to worry, he didn’t even need to look at me. He said that it happens to women at my time of life and that it would stop soon. I am waiting, and yet I feel so weak. Every day is more difficult.”

At 35, Bharati seemed young for menopause. I felt that her symptoms merited an examination, if not some extended treatment, and I was angry the estate doctor had not even examined her. I was sure she would benefit from an exam from the female gynecologist at our camp.

“Oh, there is really no need,” she said, “I am sure I will be feeling better soon.”

We had been speaking with a friendly rapport, but I reverted to playing the health professional role, and after a few more words of encouragement, Bharati nervously agreed to an exam. I completed her registration and then accompanied her to the line in front of the gynecologist’s room. I returned to the main registration queue to continue talking to others.

I saw Jagan nearby: “You have to tell the men at the registration desk to ask all the women if they want to see a ‘lady’ doctor,” I said anxiously. “The women are too shy to ask and they’re going to miss out on an opportunity to see the gynecologist!”

I watched understanding flash across Jagan’s face. Immediately, he headed to the registration desk to make our request. This approach worked much better. The doctors’ consultations went on all day.

A typical exam took place like this: The doctor is sitting behind a wooden desk. The nurse is standing, attentive, by her elbow. The patient enters and stands, (p.135) waiting to be acknowledged. She moves to sit on a stool by the side of the desk when the doctor motions her to do so. “So what is the problem?” the doctor asks, without lifting her eyes from the case sheet on the desk. The patient

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describes her symptoms and the doctor orders her to the examination table, chiding her if she does not cooperate by getting into the lithotomy position to facilitate a pelvic exam. Occasionally, if the patient resists out of fear, her legs are pried apart.

Later, we noticed the marked difference when doctors treated women whom they perceived to be their social “equals,” that is women of an upper caste. Upper-caste women were welcomed into the consultation room with a smile. Eye contact would be made and explanations given. The women would be put at ease before the examinations began.

The most common problems that women at the camp reported were white discharge, excessive bleeding during menstruation, and missed periods. The doctors examined the women who complained of white discharge (some with a speculum and some without), but most of the time they could not find anything wrong and would either prescribe ayurvedic medications or order a blood test. The doctors did not offer much advice to the patients. Mostly, they simply prescribed medications.

The experience of Lakshmi, a thin, diminutive 28-year-old woman who worked on the tea estate, was illustrative of the lack of dialogue during medical consultations. She came to the gynecologist because she had still not started menstruating. Dr. Sarojini took her into an inner room for an examination. Shortly after, she returned to tell us that Lakshmi had poorly developed female sexual organs (immature breasts and poorly developed genitals), probably due to reduced production of female hormones. Dr. Sarojini told us that this problem should have been addressed when Lakshmi was much younger and that it was probably too late to do anything about it. While she explained all this to us in English, Lakshmi was standing patiently next to the desk, waiting for something to be conveyed to her in Kannada.

Dr. Sarojini asked her to come to the hospital at Vijaygiri on a day that doctors from the nearby teaching hospital visited for special consultations. Not surprising but telling was the fact that during the discussion with Lakshmi, Dr. Sarojini provided no information about her health problem or prospects for treatment.

About an hour later, I saw Bharati standing in a corner of the compound. The kohl she was wearing around her eyes was smudged down her cheeks. She was distraught and could barely speak.

“The doctor just said that I had to come to the hospital this week to have my uterus removed!”

“But didn’t she tell you why?” I asked.

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“No, she examined me and just said to come to the hospital to get my uterus removed.” Fresh tears poured forth. “It’s going to cost so much money. And I’m sure the doctor won’t give me leave!”

I was confused. I had thought that Bharati was upset about having to undergo a surgery. “What do you mean—the doctor won’t give you leave?”

(p.136) Bharati explained that she needed to get a referral for the surgery from the estate doctor, otherwise she would not get sick leave or reimbursement for her expenses. I told her that I would go with her to talk to the estate doctor, who was also at the camp, and convince him to give her a referral to the hospital.

The doctor, a short, bespectacled man, was not someone I would see as an intimidating person. However, he clearly wielded great power over Bharati; she was even quieter in front of him, almost fearful. Later, while recounting the incident to Jagan, he explained that the estate doctors are quite powerful but also find themselves in the crossfire between estate workers and the management. Estate management wants the doctors to cut down costs and limit referrals and expensive procedures, but workers look to the doctors to help keep them in good health. The success of his job depends on his ability to establish good rapport with the workers and their families so that they follow his advice. This estate doctor seemed open to listening, and after I explained the situation to him, he agreed to give Bharati the referral letter she needed in order to get the estate’s health insurance coverage for her surgery.

Bharati thanked me profusely for talking to the estate doctor and started to cry. I went to ask the gynecologist what was wrong with Bharati. She only had a moment between other examinations to inform me that Bharati had uterine fibroids and that a hysterectomy had therefore been recommended.

I returned to where Bharati was waiting and explained what a fibroid is and how it could be treated. Bharati told me that she had been experiencing bleeding for quite some time but had not been told by any of the doctors she had consulted why it was happening. The estate doctor, who had not examined her, had just given her some tablets for stomach pain and said that the problem would go away.

While I was describing fibroids to Bharati, a number of other women, also tea estate workers, gathered around us. One of them said that she was really very happy that we had come to her village: “We have no one to talk to about our health problems.”

Yet another woman emphatically added, “It’s very important for us to know more about diseases. Doctors never give any explanations.” This lack of engagement

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on the part of doctors was brought up by several women, all of whom seemed eager for more information on health and illness.

Even as Bharati’s health concerns had been dismissed by the doctor on the estate, her fears and anxieties and her right to information had been dismissed within the auspices of our own well-intentioned program. Clearly, there was more to offering health care to women than providing them with access to doctors.

Irked by these experiences at the camp, we began to conduct monthly outreach visits to one of the largest tea estates in the area. We also made several overnight trips during which the estate management would host us at their guest house—a cottage nestled in the center of the estate, surrounded by rolling hills of verdant tea plants. On our first trip, we walked down to the “lines” with Geeta, an estate worker whose husband was the president of the local panchayat. The lines typically consist of two long single-story buildings side by side. Each houses between 5 and (p.137) 10 families. We went from door to door inviting women to join us outside for a discussion on health. Once we had invited all the women, we arranged ourselves in a circle on grass mats that the women had spread out on the ground in front of their homes and talked late into the night. Based on that night’s discussion, we decided to conduct two more evening programs—one on hygiene and the other on body aches and pains. We divided the presentation by kinds of pain and explained each one and its remedy: stomach pain, back pain, shoulder and neck pain, chest pain, headache, and tired eyes. The premise of our work was that women could take charge of their lives, take their health into their own hands.

One evening, our Jeep did not turn up to take us to the lines. We walked along the winding, tarred road through the estate for several kilometers. The sun was setting and the silver oaks gently swayed in the breeze. Neither the estate nurse or the doctor attended and everyone seemed relaxed. Nearly 40 people—men, women, and children—had gathered and there was a festive atmosphere. We set up our battery-powered lamp (as there were no street lights) and our poster board. When it came time to demonstrate the exercises for relieving back pain (a common problem, particularly among women who plucked tea leaves), we asked the men to leave. We wanted the women to feel comfortable practicing the exercises we demonstrated. The men left reluctantly and then the party began. Amid fits of giggling and laughter, Saraswasthy, one of the CHWs, demonstrated the exercises. First, the younger women stepped forward to try them out. Then one by one the others joined in. Several different demonstration circles formed and half an hour later, women were dragging their friends to the circle and teaching them the exercises themselves!

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There were these special moments when I would have a visceral understanding of the feminist texts that I read as an undergraduate at Barnard College. I drew inspiration from efforts like Our Bodies, Ourselves and an Indian equivalent called Na shariram nadi (My body is mine). During the CHW training, I drew extensively from these texts and from the literature on the women’s health movement in the United States.

The CHWs were at first shy and merely giggled through these sessions. As, time went on, they not only became comfortable with the process but began to talk about how exciting it was to actually understand their bodies. This was the experience that we wanted to extend to other women in the community.

A combination of factors usually helped me establish an easy rapport with women—the fact that I had come all the way from America to work on women’s health in Vijaygiri, that I could speak Kannada (within 4 to 6 months I was reasonably fluent), and that I was married and wore the local signs of marriage —a mangalsutra (a thread worn around the neck) and toe rings. One of the most inspiring aspects of the work that we did in Vijaygiri were these exchanges with women, when women opened up to us and shared their stories.

The Swasthya mission grew out of these encounters—we recognized that mere provision of medical consultations, the presence of health-care infrastructure in (p.138) terms of a health center, a physician, a nurse, and medicines were insufficient and irrelevant if the quality of care was poor. An important aspect of quality of care is the nature of the interactions between health-care providers and individuals: to what extent are individuals’ concerns and problems elicited? To what extent are the health-care providers’ diagnoses actually communicated? How are they communicated? Do sensitivity and empathy imbue the interaction?

We began by setting up a network of women’s health centers with a strong linkage to a referral hospital. With Dr. Vasan and Jagan at the hospital, we had assumed that care would be both appropriate and empathic. Dr. Vasan expected his junior colleagues to ask questions, observe, and follow by example. However, not all the junior doctors were sufficiently motivated and sensitive the way Jagan was. We, the volunteers and the CHWs, did not feel comfortable discussing these challenges with Dr. Vasan. Rather, we debriefed with Jagan about the insensitive and even discriminatory attitudes held by some of the junior doctors. But unfortunately, because Jagan had a degree in Ayurvedic medicine, few of the interns and junior resident doctors (practicing biomedicine) respected Jagan’s style of health care provision and his openly expressed insistence on treating all people equally.

We tried to tackle this issue of empathy and sensitivity during our team’s interpersonal interactions in a number of ways. In our training sessions with CHWs, we not only emphasized the importance of sharing information on health

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and disease but also worked on the more subtle aspects of the ways in which we shared information and the importance of recognizing and understanding the emotional and social dimensions of the interaction. Pay attention to the emotional state of the person who has sought your advice or care. Acknowledge and facilitate discussion about their emotional state. These were some of the guidelines we discussed in our training and that we tried to put into practice.

Such encounters led us to initiate the Well Woman Clinics. The main goal of these clinics was to provide empathic reproductive health care, including information, counseling, and clinical services to women. The CHWs were trained to take a comprehensive, broadly defined health history and provide pre- examination counseling to help women assess what kind of clinical consultation they required and become acquainted with routine examinations. Typically, the CHWs would offer to do a speculum examination (with visual inspection of the cervix to identify cervical abnormalities), a pelvic exam, and a breast exam. Then they would conduct a postexamination counseling session in which health promotion information and any other concerns (including the need to visit the hospital or our outreach clinic for further care from a physician) were addressed. The CHWs did not prescribe antibiotics. So, if such an examination indicated that a woman might have a reproductive tract infection, she would be referred to our outreach clinic or the hospital for further treatment. We also encouraged patients to help themselves by doing breast examinations and exercises.

Interpersonal dynamics in the health care setting were to a great extent shaped by caste and class. I was conscious of the existence of caste inequalities, perhaps in (p.139) part because I had grown up privileged. My grandfather, whom everyone in our family referred to as Anna, had rejected caste and religious divides at a time when Kerala’s rigid caste system was being challenged by lower caste–led social movements. To demonstrate his rejection, he dropped his caste surname, an act of defiance that few upper-caste Brahmins committed. Anna instilled in my father not only a nationalist spirit but a commitment to work against caste divides. My father often recalled how he would bring home a diverse group of friends, belonging to various religions and castes, and the ease with which my grandmother would feed them in her kitchen —a practice normally taboo in any caste-observant Brahmin home. Thus equality and respect were key values that imbued my formative years—a sense that all people are not only equal but have the right to be treated equally. However, the fact that my grandfather and father relinquished their caste name did not mean that we did not continue to benefit from our caste heritage. Neither I nor the other students, a few of whom had no awareness of their caste backgrounds, had expected to find that caste still remained central, particularly in rural communities like Vijaygiri.

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Shantha belonged to the scheduled caste (also known as Dalits)—historically the most disadvantaged group within the Indian caste system, the majority of whom owned no land and were relegated to the role of menial laborers. She had finished 12 years of education at an English medium school, which is very unusual for any woman in Vijaygiri. The medium of instruction in most schools in the region is Kannada; it is only a very few who have the chance to study in schools where English is the medium of instruction. Although her parents were poor and had several children, they valued education and decided to send their youngest daughter to a “convent school.” Shantha studied hard and did well. Moreover, she was acutely aware of the privilege she had enjoyed and was very interested in doing community health work.

The honorary secretary of the hospital, a devout Brahmin, recognized the importance of having a multicaste team. Further, Shantha was clearly very bright and ambitious, having earned scholarships all the way through her schooling. I was excited to find a Dalit woman with the qualifications to work for Swasthya, and I enthusiastically presented the idea to the other CHWs. Their response—total silence and, when repeatedly goaded, muted acceptance— surprised me. Although they did not openly refuse to accept Shantha as a colleague, there was marked hesitation and implicit resistance among them. Although the CHWs were all of the middle and upper castes, I did not expect a negative response from them, as they had been serving scheduled-caste clients up to this point without issue. Because of their excellent work, I assumed that they shared the Swasthya vision of equality.

For a week, there was a great deal of tension between me and the CHWs. We had the custom of beginning every meeting with a “check in,” a 30-second sharing of our frame of mind, and ending with a “check out,” another 30 second sharing about how we felt the meeting went. That week after I had communicated our interest in hiring Shanta, I felt that the check ins and check outs were strained, as though the women had something on their minds but could not say it. The situation (p.140) finally became so intolerable that I decided to take the CHWs for a one-day retreat to discuss the issue away from the day-to-day stress and rush of the hospital. We traveled outside the village to a lovely and tranquil bird sanctuary in the forest. Despite the serene beauty of the place, the tension between us remained thick. I was disappointed in their response to Shantha, and they felt defensive.

“I have no personal objections to this woman,” said one of the health workers, who seemed unable to finish her thought.

“She is obviously well educated and willing to work hard,” said another, filling in for the first, “but the truth is, if she comes into the field with us, she will not be permitted to enter the homes of higher-caste people. We will be scolded for bringing a scheduled-caste woman into their houses.” She pointed out that this

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would especially be a problem amongst the Brahmins and Gowdas, the two main upper castes in Vijaygiri. The other CHWs murmured their agreement.

“I am afraid that upper-caste community members will complain to my parents,” said another. There were more nods of assent. “My parents don’t want me to be known as one who challenges the caste system,” she continued, “In fact, I’m not even sure if they would appreciate my bringing Shantha to our own home.” I could understand her concern, as she and three out of the four other health workers were unmarried at the time, and thus answerable to their parents.

“Swasthya is meant to meet the needs of the most disadvantaged individuals and families in Vijaygiri, and Shantha belongs to the scheduled castes, the most disadvantaged of all.” I implored, “If we can’t accept one of “them” as a colleague, then how can we possibly help them overcome the obstacles they face?” Yet even in that lovely, isolated place, away from the eyes of the village, we could not find a resolution.

Up to this point, I viewed my role as project director primarily as facilitator and coordinator. I would bring together resources that local women did not have access to, help to define the problems that we would address, and identify ways in which we could address them. From my perspective, the project fundamentally belonged to the CHWs and the other Vijaygiri women, not to me. However, the CHWs’ resistance to taking Shantha on as a colleague challenged me: should I redefine my role and the nature of “ownership” over the project? My choice was to either accept their decision, going against my own convictions about the importance of hiring Shantha in furthering the fundamental sociopolitical commitment of the project, or to assert authority and set aside the participatory principles that I hoped would underlie the organizational structure.

I decided to override the CHWs’ resistance and hired Shantha. Further, I threatened to fire anyone who was not willing to work with her.

Back at the hospital the following Monday, I described my discussions with the CHWs at the bird sanctuary to Jagan. He was not only disappointed but incensed.

“No longer do we have untouchability in India!” he exclaimed. He marched over to our meeting room and launched into a tirade: “As long as you are in your (p. 141) uniforms, you are nurses—not individuals belonging to this or that caste. Caste should not enter into your professional activities.”

I do not think this lecture changed the CHWs’ attitudes. However, I realized how important it was that we critically examined the issue of caste and caste identity within our group. If it was this difficult for an educated Dalit woman to gain

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acceptance in a setting such as ours, I could hardly imagine the treatment she would get elsewhere.

In January 1999, Shantha enrolled in Jagan’s nursing program to prepare for her work with Swasthya. In addition, we thought that Shantha could shadow the other CHWs while they engaged in community outreach. Thus, she would have the opportunity to learn by observing, and we would also be able to gauge community reactions to her. In the meantime, we had also initiated plans to set up a counseling service in the hospital, and since Shantha was being trained there, we decided that she would spend the majority of her hours outside of class working in the hospital as a counselor. So the issue of caste was sidestepped to some extent. On the infrequent occasions when Shantha did go into the community with her colleagues, they avoided the upper-caste neighborhoods. I still wonder whether or not this was the ideal situation.

A couple of months after Shantha began working with us, we conducted a door- to-door reproductive health survey in Vijaygiri. Initially, we were apprehensive about what would happen when Shantha attempted to recruit individuals for the survey, which did entail going into homes to conduct interviews. Yet we faced no problems. She was never once challenged and never saw any kind of negative reaction. In fact, community members respected her in her role as a Swasthya Community Health Worker, seeing her as a health worker rather than a scheduled-caste woman. Jagan’s statement that caste was irrelevant once one donned the nurse’s uniform seemed to finally have been established.

A number of months later, I saw Shantha at the hospital and we had the opportunity to talk about her experience thus far. “How did it go for you in the beginning?” I asked. Shantha did not answer my question. Instead, she told me, as she had many times before, how pleased and honored she was to have the job.

“Please, Shantha, it’s important for me to know about your experiences, especially in the initial days.”

Although reluctant to voice displeasure or discontent to me, she finally revealed the pain that she had experienced. “I was hurt,” she said, “particularly by Anita.” Anita is an upper-caste CHW with whom Shantha spent time in the field, and I had thought Anita would be a help to her. Shantha had been of the same mind.

“I thought Anita would be my greatest source of support, but she turned away from me, as did the others. Usually she would turn away when another was there; if one of the other CHWs was also present during outreach, the two of them would talk and walk together, leaving me out. At our weekly meeting days at the hospital, everyone would sit together and eat and talk, but no one would talk to me. I know they did not want me here.”

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(p.142) Shantha had been hurt and sad but unable to talk to her parents. “I haven’t talked to anyone about this until today. You know that my parents are old and my sister is always worried about me. I wanted them to think that I was happy here. And I am. I am so happy to have this job,” Shantha said in her quiet, composed way. She was new to the hospital environment and did not have any friends or support in the hospital itself. I was the boss, and so she did not feel comfortable coming to me because she did not want to me to think that she was complaining. She had suffered silently, thankful for the position and determined to make the most of it.

“Things are getting better now,” she said, “I am glad the survey went so well; I can feel that the others are beginning to trust me.” But what struck me was the fact that I had not stopped to think of what the ordeal must have been like for her. Of course she knew that her caste status was an issue with the other CHWs, and they had made it clear to her, perhaps fueled by resentment at my insistence that they accept her.

At this point, we, the group of international students, decided to consciously confront caste inequality and build alliances with groups that were trying to promote the interest of the lower castes. Jagan, too, felt passionate about this need. His sensitivity and political commitments sometimes surprised the student group and always elicited respect from them. Jagan was born and brought up in Vijaygiri, steeped in the cultural milieu, yet he seemed acutely aware and unaccepting of these entrenched inequities. Jagan pursued connections with a Dalit group and a tribal development group. The tribal development group invited us to give a presentation at one of their festivals and printed pamphlets that had our names on them as among the invitees. Someone at the hospital saw the pamphlet and got very upset because the tribal group was engaged in political work. Hospital staff for the most part believed that their work was apolitical. Although a number of hospital staff engaged in politics in their personal time, their job was to provide health care to all, and therefore they felt that they should not take a political stand.

The hospital was set up by an ashram originally founded by Shankracharya, a Sanskrit scholar who lived in the eleventh century. He was responsible for the revival of Brahmanical Hinduism in South India at a time when Buddhism and Jainism were gaining popularity. Brahmanical Hinduism is a more conservative form of Hinduism in which Brahmins dominated. The ashram is a very old, powerful Brahmin institution. It runs a Sanskrit school for Brahmin boys and trains them to be priests. About 20 years ago, the leader of the ashram, the Swamiji, who was committed to serving the local community, founded this hospital. The hospital administration was willing to accept our work to promote women’s health and even, to a certain extent, our efforts to promote women’s leadership. But they were unwilling to accept a collaboration with a group that was explicitly political. This posed another dilemma, whether to distance

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ourselves from the political struggle for tribal and scheduled-caste equality or to jeopardize the partnership with the hospital on (p.143) which our program was founded. We decided that our partnership with the hospital was so crucial to the functioning of our program that we would have to accept the attendant constraints. Thus ended our links to the tribal development group.

One morning, we traveled to a Dalit colony to visit Lalitha, a woman who was in need of our help. The colony was deserted because everyone was out working in the fields, but Lalitha was at home; she was lying on a straw mat in the corner of her one-room mud house. She had been unwell. Three years prior to our meeting she had started having health problems and had to stop working. She had two sons, who were 15 and 12 years old at the time. Both had been good students, but she had to take them out of school to work, to compensate for her lost wages.

Before her illness, Lalitha would go to the fields at about 6:30 in the morning and return home around 4 in the afternoon. Some of the landlords who are more generous give the workers some buttermilk and rice at lunchtime, but there are many that give absolutely no food at all. Therefore, many workers might eat something in the morning and then not eat again until 4 or 5 in the afternoon. The going wage in this area is 25 rupees a day (about 50 cents). The basic diet is rice and a watery curry with cucumbers, which has very little nutritional value. Lentils, which are part of the staple diet of the upper castes, are unaffordable for people like Lalitha. They cost about 15 to 20 rupees a kilo. The work was constant, and Lalitha and her husband were in the field every day, vowing to work so that their sons could finish school.

When her health problems led to economic hardship, Lalitha’s relationship with her husband began to deteriorate. She had been experiencing burning, pain, and anger during sex. “I started to feel really tired. In the evenings he drinks. Then he calls me to sleep with him, and we fight because I do not want to…. My husband took me to see a doctor who gave me some tablets, saying that once my head was fixed, all my diseases would disappear.”

It was difficult for me, as a nonphysician, to really make sense of Lalitha’s symptoms. Much has been written in India about women’s experience of fatigue, locally known as susthu. When we were presenting exercises to women in Vijaygiri, we would ask them—in groups and individually—to list the major health problems that women in their area experienced, and susthu was always mentioned. Susthu might be a result of anemia and the hard physical labor that most women engaged in, and may have been compounded by the other more psychosocial stresses (arising from poverty, marital discord, trouble with neighbors/landlords/bosses, raising children) that women, particularly poor, lower-caste women, coped with day in and day out.

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The pills that Lalitha had been given were tranquilizers, meant to sedate rather than cure her. After several years of taking such drugs, trying to figure out what was wrong with her body, and receiving no answers, Lalitha was feeling weak and disinterested in life.

Although Lalitha and her husband spent whatever little money they had in visits to private physicians, the doctors could not diagnose her properly. They had (p. 144) gone to the full range of health-care providers: village healer, a man who used herbal remedies to treat illnesses, the local ayurvedic doctor, the registered medical practitioner, and allopathic/biomedical practitioners. They branded her neurotic, a “basket case” for whom little could be done. They did not see that when she left their office, she would return to the stresses of her everyday life— poverty, marital discord, and the burdens of raising two sons. These were invisible to the doctors. Caste segregation is so complete that the physicians could not know these things and so could not know of the despair that Lalitha felt about her life; in other words, they could never truly address her problems.

The Swasthya research teams found that Lalitha’s case is not unique. Her story mirrors that of many women in Vijaygiri, who have no choice but to go to physicians with physical manifestations of problems related to stress and social and economic hardship. Although these women are in need of social and psychological support, physicians rarely recognized this.

I had accompanied our young physician interns on a weekly visit to one of our Swasthya health centers. We went in the Swasthya jeep, with the men—the two interns and the driver—in front and a Swasthya CHW, two nursing assistants from the hospital, and me (all women) in the back. The interns, young men in their early twenties studying at a nearby private medical school, were discussing the “regulars” they were expecting to find at the center.

“I hope that lady is not there,” said one.

“Which one?” I asked from the back. I always tried to listen in on these conversations to get a sense of what was happening at the centers.

“You know, that crazy one. She comes every week, complaining of one thing or the other—headaches, stomachaches, exhaustion. There’s nothing wrong with her. She looks totally healthy,” was the reply.

Sure enough, when we reached the center, there she was.

These women, like Lalitha, typically walk away with a questionable set of tablets —vitamins and tranquilizers, for example. They walk away believing that these medicines will suffice to solve their problems. The fact that many of these problems arise from a combination of socioeconomic, cultural, and physical

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circumstances and call for more holistic interventions escaped both the physicians and the women themselves.

A Swasthya CHW visits Lalitha often, providing her with emotional support and encouraging her to participate in programs at the health center. The CHW also provides counseling to Lalitha’s husband, attempting to make him more sensitive to the pressures Lalitha feels and to confront the violence in their relationship. The success of the CHW’s efforts to support Lalitha is limited, however, by the sociopolitical and economic differences between them. The CHW is from an upper caste and is educated. Thus Lalitha and her husband, regardless of whether or not they wish to have her there, are obliged to allow the CHW in their home and to listen to her. They see her leave the colony every evening to return to her home in the more privileged section of the village. Although she is trained to be more sensitive (p.145) than the physicians Lalitha has seen, she is also unable to truly understand what it is like to live as a Dalit in a colony. No matter how long she works there, the CHW will always be an outsider.

Gender, caste, class, and nationality create hierarchies of power and knowledge even within our own group. The authorities at our partner hospital and within the community tend to be men of the upper caste/class. The honorary secretary, the chief medical officer, the head of the laboratory, and even Jagan were all Brahmin men. Even among the nursing staff at the hospital, the matron and many nurses were either Brahmins, other upper castes, or Christians. The women who swept the hospital clean were Dalits. The CHWs, although relatively diverse in terms of caste and class, are privileged because of their training and employment. I, the program director, am a citizen of a globally dominant nation; in part, I have that citizenship because of the privileges that my family enjoyed based on our caste status in India. Given my own caste background and the fact that I was highly educated, to the level of a doctorate, gave me considerable voice. I was in a completely different category. And the struggle for me was to use this strategically—to protect and facilitate the interests of those who were not always heard, including the CHWs, within the prevailing power structures.

Community mobilization requires sustained community involvement and action. This was the weakest aspect of the student-driven model that we were pursuing. Given that students are students only for a short time, a model that is student- dependent is extremely difficult to sustain. In fact, it is likely to be unsustainable unless there is a stable core leadership. Our plan was to work with the CHWs until they could plan and carry out programs on their own. They would form the core group, with Jagan in a leadership position.

Over time, we grew concerned that Jagan was constantly torn between the needs and perspectives of the administration and the CHW/student group. We decided that the CHWs themselves should have greater leadership responsibility.

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In reality, we found that 3 years of working with the CHWs was not enough for them to reach this level of autonomy. They had not reached a point where they could continue to innovate and bring to fruition a vision on their own. Our trips to Vijaygiri over the fourth and fifth years revealed that, for the most part, the CHWs were carrying out activities that we had discussed and planned over the course of the first 3 years. Real innovation had not occurred.

According to one member of the student group who conducted an informal evaluation of Swasthya activities,

When asked if they would like more education or would want any changes in the program, most community residents felt it was nice to have the CHWs come to their house and they would listen to whatever they said. However, these types of comments were made in a way suggesting that they did not really use the information—they just listened to it and were happy that someone was doing good work in their community. It did not seem that anyone was greatly dependent on these visits or that they would be greatly missed. However, (p.146) people did express that they had come in for certain tests and checkups to the hospital at Vijaygiri because the CHWs had encouraged them to do so. Most people seemed to feel that it was helping people in the community and good for the village, even if they themselves did not utilize the resources/information.iii

The project finally wound down 5 years after it began. The student group’s involvement had come to a close after the first 3 years, but we continued to raise small amounts of money to keep the project going. However, we began to finish our degrees and move on with our lives. (I was 7 months pregnant with my second child and on the faculty of the University of California, San Francisco, by the time Swasthya closed.) In our occasional communications via e-mail, it became apparent that there was increasing unhappiness with Swasthya’s governance, the lack of recognition and independence the CHWs had, and the evolution (or perhaps I should call it stagnation) of the program. A few members of the initial student group continued to visit Vijaygiri and found that the CHWs were still giving the same presentations, skits, and role plays that we had developed in the early years. The CHWs also voiced concerns during these visits: they wanted more stable employment.

At the end of a series of discussions with the hospital, we realized it was unlikely that we would be able to resolve these concerns to everyone’s satisfaction. Finally in December 2002, we and the hospital decided to end the partnership.

Each of the CHWs has followed a unique trajectory. Each, I feel, has been touched deeply by the project. Swasthya did provide opportunities for self- expression and independent thought and action—opportunities that few young women, particularly those in rural areas, have access to even today. They opened

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and operated bank accounts—some with the support of their families and others clandestinely. Nearly all the CHWs continue to work and pursue careers today. Shantha and Anita are roommates and work as nurses in a large clinic run by a friend of Dr. Vasan’s in a nearby district. Several others are in similar employment. One CHW became involved in village politics; another got married and stopped working.

Jagan remains at the hospital, continuing to run the “nurse aid” training program. The hospital has expanded since my time there. They now have a government-accredited undergraduate nursing college that has overshadowed Jagan’s program. The nursing college is staffed by teachers with bachelor’s and advanced degrees in nursing and follows a state-approved curriculum. However, the graduates of Jagan’s program are still in demand; many small nursing homes continue to look for lower-paid nursing staff and do not care whether their employees have a recognized degree or not. Jagan continues to raise funds through local clubs and associations in order to run outreach clinics. In his desire to keep innovating and contributing to local health promotion, he became certified in counseling through a part-time program offered in a nearby city and received a degree in health administration through a distance learning program. He had hoped that this degree would help him move into a hospital management position. However, the power structure within the hospital has been so entrenched that his plans have not materialized. (p.147) Despite the loss in stature of his nursing program, his unrealized dreams of engaging in mass health education and outreach and his failed attempt to take on a greater administrative role at the hospital, Jagan remains cheerfully optimistic. He and his family visited me a few months ago. In response to my barrage of questions about everyone at the hospital and the goings on, he replied, laughing, “Everything is the same!”

ACKNOWLEDGMENTS This chapter builds on a paper coauthored with Rajesh Vedanthan titled “Experiences of the Perils, Pitfalls and Inspirations of Public Health as Social Justice: The Swasthya Community Health Partnership, India.” I am grateful to Raj and my other Swasthya colleagues for the enriching experiences and relationships that continue to inspire me.

Notes:

(i.) Names of places and individuals have been changed.

(ii.) Village government.

(iii.) Tantri, A. Personal communication.