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Student International Health Initiative
India Field Research Write Up Part 2
By: Cindy Escobar, Adnan Piirbhai, and Neilesh Soneji
This module outlines information and observations collected on common illnesses amongst the rural Garhwali population. The focus of research was on diarrhoea, intestinal worms and pneumonia. The purpose of the research was two-fold. The first purpose was to determine prevalence and perceptions of these illnesses amongst rural populations in villages surrounding Jan Vikas Sansthan. The second purpose was to determine the challenges in alleviating illness amongst rural populations of Garhwal. Several sources were consulted during research, including village women, village men, primary health care workers, and NGO workers. Notes are reported on each interview conducted. The layout of the documentation maintains the following format:
Source - location of interview and names of interviewees
Source Background - description and background of interviewee
Illness being studied – diarrhoea, pneumonia or intestinal worms.
Prevalence of Illness – an indication of the prevalence amongst the population
Causes of Illness – perceived cause of illness according to interviewee
Treatment of Illness – treatment methods utilized by interviewee
Other Information – notable information including analysis and observations
This format is repeated 6 times for 6 different interview settings. Thus, the documentation is divided by successive interviews, not interview topic. This format allows for information to be accessed as it was recorded during research throughout our stay at Jan Vikas Sansthan from May 15 May 28, 2001.
The information collected in this work, is informal research that should not be utilized in designing public health policy. Rather, this information may serve as a basis to conduct further systematic research on common illnesses amongst the Garhwali populations. This research may provide insight into common cultural perceptions of illness, and the challenges public health officials may face in developing effective public health programmes.
Interview Date: May 15th and 16th, 2001
Source Information: Titrana Gaun in Garhwal.
Primary Source: Village women from Titrana Gaun
Approximately 15-20 village women were interviewed by 8 female SIHI members. The conversation took place in a casual group setting over a period of 2 days. Women came and went during conversation and were not entirely the same for both days. This group was considered our primary source because of women’s role in raising children and because of the group size.
Secondary Source: Common village man
One village man was interviewed over a period of two days. His occupation was a driver in the plains of New Delhi. He was home on vacation and had time to spend with 6 SIHI male interviewers and Dr. Sachin from Manthan Associates. The interview location was his home.
Tertiary Source: Primary Health Centre pharmacist
All SIHI members visited the PHC and interviewed a pharmacist about the facilities of the PHC. He answered several questions on Diarrhoea with the help of a midwife and an eye assistant. The PHC is distant for many users and often unreliable. There seems to be a communication barrier between the PHC and the villagers.
Illness being Studied: Diarrhoea (ages 0 – 5 years)
Garhwali name: Ubu, pechis, ubu-undu
Hindi name: Dast
Prevalance:
· More prevalent in summer according to both village women and pharmacist
· Approximately 20% children are afflicted with Diarrhoea in summer (PHC studies)
· Diarrhoea is less prevalent in winter. 2/100 children afflicted (PHC studies)
Causes of Disease:
According to Village Women
According to Village Man
Primary Health Centre (PHC)
Treatments:
According to Village Women
According to Village Man
Primary Health Centre (PHC)
Other Information:
Original Completed By: Cindy Escobar
Typed by: Neilesh Soneji
Interview Date: May 22nd, 2001
Source Information: Chuckreta Village in Garhwal
Source Background:
This village is located by the roadside which could potentially provide this village better access to supplies and medicines. It has a water source available at the bottom of the village as well as a lake somewhat near by. Although tapped water is available in village it is unreliable it comes and goes as it pleases. This village seems a lot dirtier than others visited in terms of pathways having more dung and garbage as well as the people looking less clean. This village consists of 250 families and is primarily civil caste. The village is 10-12km from Jan Vikas Sansthan.
Our sources were village women mainly but some men were present in the meeting. Throughout our visit we were escorted by the village head person’s (a woman) son. He assisted in some of the discussion and was present throughout which may have influenced villager’s responses.
Factors affecting results was the Kamla was sick and seemed not to translate questions or response thoroughly. The discussion was held in front of the village’s primary school. All SIHI representation were present in the discussion (boys and girls).
Illness Being Studied: Cough (target age 0-5yrs old
Hindi name: Cansi
Garhwali name: Casu
Causes of Illness:
Treatments for Illness:
Other Information:
Original Write-up and Documentation Completed by: Cindy Escobar
Typed by: Neilesh Soneji
Interview Date: May 24th, 2001
Source Information: Badyar Gaun in Garhwal
Source Background:
Badyar Gaon is located approximately 2-3km away from Chirbatiyah. It is closer to the road than Titrana Gaun. We visited the primary school today and observed the daily lives of school children at school. Then we chatted with an elderly ex-military man about our health care manual. This Gaun was mixed caste. Takhu Caste, Rajput Caste and Schedule Caste.
Primary Source: We spoke with an elderly man for approximately 1 hour today. He was an ex-military officer with a substantially well-constructed house. Doubts were raised as to the effectiveness of the responses he shared. He was being questioned heavily in regards to daily lifestyles and health issues of children. Perhaps as a man, he was unaware of these issues. We sat in his home during the interview.
Illness Being Studied: Diarrhoea
Garhwali name: pechis, dubu
Hindi name: dast
Prevalence of Illness:
Causes of Illness:
Treatments:
Illness Being Studied: Stomach Worms
Garhwali name: Jonku, Hariyal bimari
Prevalance:
Causes of Illness:
Treatments:
Other Information:
Original Write-up and Documentation Completed by: Neilesh Soneji
Typed by: Neilesh Soneji
Interview Date: May 25th, 2001
Source Information: Interview with Mrs. Ananta Chadda (Didi) – Jan Vikas Sansthan
Source Background:
Didi has been a secretary at Jan Vikas Sansthan for the past 12 years. She just recently attended a conference in Dehra Dun where some of Uttaranchal’s most recent health statistics were discussed. She has had extensive experience in the development field, particularly with our host NGO (JVS). Our interview lasted approximately 1 hour. Ayesh Laldin translated. The interview took place at JVS. More so than a question answer session, Didi offered us an introduction into these topics and her experiences as a development worker. The goal was to understand her perspective of these illnesses in the surrounding Garhwal villages, villager interpretations, and difficulties in conducting development health care work.
Illness being Studied: Diarrhoea
Prevalence:
Causes of Illness and Perceptions:
Treatment:
· One of the most important factors in treatment is location of village. This principle applies to health interpretation and all illnesses.
· Villages who are further from the road head have more traditional lay beliefs. They interpret health in this manner and seek treatment in this manner.
· Even villages at the road head hold these beliefs, but usually not as strongly. They often resort to allopathic treatments.
· Some people incorporate both beliefs and treatment. They are at greatest risk financially, because they seek both treatment/medications.
· Every four villages or so, has an Ooja doctor. People are said to visit these doctors for everything from fits to cancer, to moodswings, to bumps on the leg.
· There is a Devda in each village. The Devda is a spirit or a good person who used to live in the village. If someone is sick they call the Devda through a drum ceremony. The Devda possesses this villager. The villager can request something of the village for cure i.e. animal sacrifice (not as prevalent anymore).
· This is a belief that has developed and passed down over generations.
· The Ooja doctor does manthras and does not ask for any money explicitly. Nonetheless, the people end up paying as he has a donation jar. Many Ooja’s are said to be fraud, but people believe in them and continue to poor money into them.
· Remote villagers believe wholly in this Ooja and Devda system and do not accept allopathic medicine. Also, when they finally go to allopathic treatment, many people pass away because treatment is too late. This hinders belief in the allopathic treatment.
· Also Devdas can be quite expensive. Socially, people are invited and have to be fed etc. Animals have to be sacrificed etc. (i.e. 1200 rupees/goat)
· These treatments are not always second preference.
· Baisakilal’s story of his sickness when he was young. Devda was called, he got worse, Doctor forcibly injected medicine, and that’s what saved him. Since then, less animal sacrifice because of his social work and advocacy.
· Chakrata uses the temple across the JVS as its Devda Centre
· These beliefs were said not to be shared with us, as we are seen as educated and not accepting of these beliefs.
· Baisakilal knows a root that’s good for diarrhoea.
Other Information:
· Try to find out names of roots for Diarrhea treatment from Baisakilalgi.
Illness being Studied: Pneumonia
Prevalence:
· Pneumonia is said to be most prevalent in winter
· Huge child killer, particularly in villages where Ooja and Devda is most prevalent
Causes of Illness and Perceptions:
Treatment and Perceptions:
Could it be that people feel more aware in that culture and so don’t just explain symptoms and expect the doctor to know or explain what it is and why it has happened. There is a different form and outlook of reporting what the illness is. This could lead to different forms of diagnosis and treatment.
Other Information:
· Ooja doctors and Devdas are most challenging obstacle for development workers in health
· But things are changing slowly (i.e. immunizations)
Interview conducted by: Neilesh Soneji, Adnan Piirbhai, and Cindy Escobar
Translator: Ayesha Laldin
Documentation written by: Neilesh Soneji
Typed by: Neilesh Soneji
Interview Date: May 25th, 2001
Source Information: Interview with Jan Vikas Sansthan workers– Jagdishbhai, Dineshbhai, and Nagendar bhai
Illness Being Studied: Diarrhoea
Hindi Name: Dast
Cause of Illness:
The workers made immediate reference to water supply as a cause of this illness. Open water sources i.e. flies on the water pot, are another major cause of illness in summer.
Old or rotten food is another source of bad hygiene i.e. basikhana or bhojan foods. Food may be left from morning to night or overnight before being consumed. This may give off odours in the summer.
Sanitation is another major cause of illness according to these workers, i.e. dirty nails/hands, frequent carelessness with feces and hand sanitation, walls made of mud.
Treatment:
The workers suggested washing hands with ash as a method of better sanitation.
They mentioned that Ooja doctors (Baki) are often a means of treatment of village people. They emphasized that illiterate people/regions make more use of this resource than literate people.
Gods are called upon for help through the form of prayers
The workers suggested seven steps towards better health in villages
Safe drinking water
Supply of unused water
Latrine use effectively
Safe and effective garbage disposal
Sanitation of food and homes
Personal hygiene (i.e. hand washing and cloth washing)
Environmental sanitation (water and barns)
Other Information:
The workers suggested that villagers are often reluctant to accept awareness programmes like hygiene education programmes.
They suggested villagers are more open to infrastructure programmes like Swajal. This outlook is said to be limiting in the progress of the village.
Illness Being Studied: Pneumonia
Causes of Illness:
The workers suggested that pneumonia is more frequent in the summer months than the winter months.
They attributed this frequency to children not being as heavily monitored in the summer. (I.e. they may playing cold waters carelessly and contract a cold and fever, which builds towards pneumonia, also cold milk given to children may lead to problems.
Change in temp are said to cause pneumonia. Children are said to often die from pneumonia.
Treatments:
Not discussed
Other Information:
These workers are the first source that suggested that pneumonia is in fact more prevalent in the summer than winter. This was surprising, and they said they were certain of this observation.
Interview conducted by: Neilesh Soneji, Adnan Piirbhai
Documentation written by: Neilesh Soneji
Typed by: Neilesh Soneji
Interview Date: May 27th, 2001
Source Information: Interview with Bengali Doctor in Ganzyali
Source Background:
This Bengali doctor was formally trained in Ayurvedic medicine. He shifted towards a combination of Ayurvedic and Allopathic medicine because of the demand for allopathic treatment in the area. His facilities were fairly basic and he professed his approach of applying or administering medicines on the basis of symptoms. He suggested that many people also came in with Diarrhoea.
Source Information: Interview with homeopathic doctor in Ganzyali
This Homeopathic doctor was trained in electron homeopathy. He moved towards allopathic medicine as a result of demand for allopathic treatment and lack of awareness in the villages about homeopathy. He sees 20-25 patients a day. Perhaps, what was most interesting was that he often faces cases where people only place partial belief in his system of care, while belief is also place in traditional practices such as Devda’s and Ooja doctors. He said people often come to him with viral or bacterial diarrhoea. They are often unaware of their own illnesses and only after questioning them can he decipher which illness they have and that he must treat. He also stated that even if people have bloody stools, they wait many days before coming to him. He said diarrhoea is a huge problem here, especially amongst poor people who often visit him.
I wonder if he attributes the wait between recognition of illness and visiting him to the financial situation of the patients. They jus may not have the option of visiting him. We never inquired into his costs or fees.
He discussed in detail Jonku (worms). He said people often misjudge this illness to be simply diarrhoea. He was also at one point unsure of the symptomatic differences but realized that ehd anti-diarrhoeal medicines he was administering were not effective, so he switched to antibacterial worms medication which was effective. This case may reveal lack of awareness on his part. Still he feels, that he provides an effective and useful service to the patients. Worms is said to be most prevalent in winter (not in summer).
Anecdotal evidence of difficulties in health care – People may only come to him with Jonku after Ooja doctors, are traditional practices fail. This means the severity is often worse when he is confronted. After he diagnoses the Jonku correctly, medication is offered. Still people offer prayers afterwards in thanks of the cure. This indicates a strong faith in spirituality and its role in healing despite, allopathic or ayurvedic medications.
He said he give referral to Dehra Dun but not really PHC because he believes PHC are not much better than his own. Overall, he says people search for traditional methods of healing prior to seeking his help/expertise. He carries supplies and medication and sells them. One other homeopathic doctor is this region. He too has integrated allopathic practice.
Interview conducted by: Neilesh Soneji, and Cindy Escobar
Translator: Ayesha Laldin
Documentation written by: Neilesh Soneji
Typed by: Neilesh Soneji
Interview Date: May 28th, 2001
Source Information: Interview in Dharti Gaun in Garhwal
Source Background:
This village is former home to Baisakilalgi and his family. The interview was conducted in a primary school that was currently being constructed. It was partially opened and classes ran during the days. This project was funded by an SDM (deputary magistrate). It cost 1-2 Lackhs to build. The females and males separated for today’s session. The men’s interview was quite informal and was interpreted and led by Mr. Saji Kumar. Approximately 6 men continued to answer questions. There was representation from both the younger and older generations. Approximately 20-40 families lived in this section of the village. The village was mixed caste. 50% of men are said to stay in the village, but in this community, only 5% leave the village.
Illness being Studied: Diarrhoea
Causes of Illness:
Stomach problems are said to occur more frequently in the summer.
On average 2 children die from diarrhoea
Shortage of money is related to children with stomach problems (i.e. perhaps a reference to nutrition or sanitation levels)
Treatment:
Jaributhi (herbal medicines) are often used for diarrhoea
25 years ago people in this village used to be more knowledgeable in their herbal medicine fields.
Now fewer people are said to know or practice this process
People now rely more on allopathic medicines because of instant relief. This is recognized as a problem because people don’t have money to access these allopathic medicines, nor do they have doctors to treat their illnesses.
Access to doctors/hospitals is said to be very difficult because of distance and money.
There are said not to be Ooja doctors in this region
People are said to rely on Devda and Gods for relief.
Prayers are offered in times of illness
Herbal medicines i.e. athis (stomach), and Kadvai mixed with cold water (fever/stomach).
Other Information and Insights:
These people seem to be trapped between several forms of treatment for different reasons (i.e. generation interpretations and shift towards allopathic treatment despite poor access and understanding)
Education is seen as advantageous in this village for farming techniques. This could perhaps be extended to practical means by which to prevent illness. Note farmland is split amongst male children and many men end up having to perform labour jobs. It was insisted that it was better if children didn’t leave the village once educated. The school prior to this newly constructed facility was quite far away, located in another town.
Illness Being Studied: Pneumonia
Causes of illness:
These illnesses are said to occur most frequently at the end of summer and beginning of winter (seasonal change)
They also occur in summer months alone
Tends to become severe and quite dangerous to the point of mortality in some children
Treatment:
Poor families are said to be victims of severe cases because they cannot access professional medical care.
Herbal medication. Koot (fever for all ages), kadvai (fever and stomach), Neelkhandi (below 5 years of age)
Illness Being Discussed: Worms
Causes of illness:
Sweets
Unripe fruits
Children become weak (i.e. perhaps a reference to malnutrition. It is known that worms ingest nutrition)
Worms described as double headed (hook worms)
Treatment:
Athis, Kadvai
Neelkandhi (below 5, vomiting , chest pain, fever etc.)
Other Information:
Worms are said to travel towards brain
If they reach brain, children pass away?
This illness was identified as very common in children
Trust in God as a healer may result in questioning one’s faith
Water is not said to be a problem in this region
Evidently, common illnesses such as Diarrhoea, Pneumonia and Intestinal Worms severely afflict the health of the population of Garhwal, particularly children under the age of 5. This observation correlates with previous studies conducted on the topic. A perception of the causes of illness varies amongst the local villagers, men and women, primary health care workers, and NGO workers. The different perceptions of illness make it very difficult to implement effective public health programmes and education. Furthermore, the health seeking practices of rural populations is pluralistic. Folk healers are still predominant in this region, as is self-care. Biomedical doctors are also consulted as a means of therapy. Health seeking practices often seem to be based on perceived personal needs, cultural socialization and accessibility, particularly in terms of financial resources. Though pluralistic options can be beneficial to particular groups, it appears that this situation also often leads to confusion and ineffective health care. Continued NGO involvement through educational programmes appears to be an important method by which to improve health standards of this regional population. Also, more accessible and efficient Primary Health Care facilities could serve to improve trust between government sponsored health care officials and rural communities. The reduction of common illnesses should take high priority in this region. However, there are several challenges, which make it very difficult to sustain such improvement. More comprehensive studies must be conducted to effectively determine the needs basis of the rural regions of Garhwal. Only then can government sponsored health programmes be effective.
Title: Hygiene of Pre-Schoolers (ages 5 and under) – Summary Report
Extended Title: Lifestyle pattern, hygienic practices, and hygienic disorders of children 5 years of age, and under, living in Rural Indian Mountain Village, RIMV. (Surrounding area of Chirbatiya, Garwhal region of Uttaranchal province)
Motivation: The choice of this topic was primarily motivated by the direction of Dr. Karen Trollope and Dr. Pradeep Kumar. As a result of their previous experience and knowledge, they see the hygiene of preschoolers as a distinct topic with unique significance. From observations made in our field work, such a topic was justified since pre-schoolers (ages 5 and under) are consistently a distinct subset of the overall RIMV population. The vast majority of children five and up DO go to school, wheras those 5 and under have similar daily schedules and do not do any work (housework, fieldwork, or otherwise. In addition to being a distinct population subset, pre-schooler hygiene can be considered a topic of significance deserving attention for several other reasons. First, since the pre-school population demonstrates similar lifestyle patterns across the RIMV – the children often display collectively similar hygienic practices and are thus affected by a consistent set of hygiene disorders*. Thus, it is possible to conduct an organized and objective study into the hygiene perspective of this sub-group. Secondly, the hygiene behaviours children engage in at this early age can set the foundation for future practice. Finally, as children under five, pre-schoolers are not people with mature rationale and/or immune systems. As a result they are less likely to pay attention to matters of personal hygiene and ultimately are particularly vulnerable to disorders that are due to lack of hygiene.
*By hygienic disorders, we mean to say such afflictions brought on by poor hygiene practice. These include: scabies, lice, ringworm, etc.
Purpose: The purpose of this topic was to develop a holistic perspective on the hygiene of RIMV children of ages five and under. Ultimately, this module is to be integrated with other topics related to the health situation of the people inhabiting RIMVs so that an overall health perspective can be obtained. This integrated research format could then be used to aid in the creation of a primary health care manual that is culturally specific to RIMVs.
Methodology: In developing a holistic perspective on the hygiene of rural Indian mountain children of ages 5 and under, three categories of study were identified. These were a literature review, interviews conducted on villages in the Garwhal region, and interviews conducted on health care workers and development workers in Garwhal.
Initially, a literature review was conducted into common hygienic disorders suffered by children. In order to narrow the scope of hygienic disorders to those endemic to RIMV children, guidance was provided by Dr. Trollope/Kumar (who have had knowledge and experience in this topic) Through this guidance, 5 hygienic disorders were identified as prevalent and deserving of attention and study. They are: scabies, ringworm, headlice, eye infection and ear infection. The literature review was necessary to provide us with an initial general understanding of common hygienic disorders. It helped to aid us in what questions to ask and in comprehending and interpreting the answers given to us by the villagers and health authorities we would interview in Northern India.
The second category of study identified was the actual on-site field research into the hygiene perspective of pre-schoolers in RIMVs. This category is divided into two sub-categories: Interviews/ observations conducted in RIMVs and interviews conducted to health authorities/development agencies that serve RIMVs.
In developing the holistic hygiene perspective, three sub-areas of study were identified: the daily life routine, the hygienic practices of RIMV pre-school children and the hygienic disorders affecting RIMV pre-schoolers. To this end, interview questions were designed to cover these 3 areas. These objectives were developed from the very onset. The rationale for this is that: discovering daily life routine provided information on the micro-context of which we were studying hygiene in; the hygienic practices indicated to us to what degree and how the children were hygienic or not; and information on hygienic disorders (the diagnosis, perceived aetiology, and treatment) would reveal to us their beliefs and perhaps rationale for their behavior towards hygienic disorder. We also found that this order of questioning to be most beneficial since it is less intrusive and thus provides greater potential for casual conversation and rapport that lead to success on more sensitive topics.
In collecting information from the villages, interviews of villagers as well as general observations of village conditions and people were conducted. In each village, to ascertain the macro-context in which the hygiene research and conditions are embedded, note was made on such general information as caste of village, size of village, and description of source interviewed . This general information was crucial as it could account for source bias and could be used to ultimately explain certain patterns in the health care perspective of RIMVs. In terms of the interview questionnaire, the methodology remained semi-structured throughout, but did increase significantly in structure as the study progressed (time passed, more villages visited). This is because in our initial interviews, we had only our 3 sub-categories of hygiene study in mind when we asked questions. We began to notice the fact that as situations change, our questions changed and sometimes these inconsistencies in procedure could result in biased answers or leading questions. To eliminate this, or at least minimize such inconsistencies, we formulated a structured questionnaire (appendix A) from which all interviews to villagers were conducted. Certainly, our “thought-out” set of questions designed to eliminate researcher effects had bias’ of their own implanted – however, at least the bias remained consistent. This, we surmise, is better than constantly changing procedures that we did not even keep a record of. Regardless, although our interviews increased in structure as a result of a clearly defined questionnaire, the reality is that the interviews were still only semi-structured. We would edit the interview/question procedure from village to village due to such factors as: lack of time; fatigue of villagers/our interpreters; misunderstanding or non-comprehension by villagers/ourselves; or certain responses by villagers were unique and unexpected. Unexpected responses would prompt us with an improvised line of questioning. In total, 6 villages were visited and interviews conducted. At each village, an attempt would be made to gather the village women (6-+20 women and children as more and more villagers would gather as the interview progressed) to interview them on their daily routine and to discuss hygienic practices and common afflictions affecting children. This approach was deemed as the most beneficial to our study since it is women that deal primarily with practices of hygiene and child care. While we were largely successful with this endeavor, there were times when, due to the sensitivity of the situation or interview environment and topics, we would only be able to have female members of the team conduct interviews with the women and have the male interview a male. In other cases, when women were not available we would interview a male or group of males in the village.
In order to further our perspective on hygiene of RIMV pre-schoolers, we explored sources other than the mountain villages. These sources included the primary health care centre (PHC), a state run health care centre that is meant to be an important agent in dispensing primary health care. We also interviewed Didi, the secretary at the Jan Vikas Santhan NGO. As an NGO with broad developmental project operations in the area – Didi, the secretary, had a fairly developed perspective regarding pre-schooler’s hygiene in the area.
In interviewing the pharmacist, eye doctor and midwife at the PHC, a very informal interview approach was employed. We were unable to have a formal in depth interview as we were interrupting their work day to interview them - nor did we adequately prepare a set of questions.
The interview with Didi, however, was very structured with all questions asked listed in Appendix B. Since we conducted this interview towards the end of the field research conducted on villages, we used this as an opportunity to ask questions that confirmed past findings, to get explanations for inconsistencies and to acquire advice on new directions to take our research.
In general, it was found that the pre-school children of the RIMV regions lead a fairly consistent life profile from village to village. The vast majority of testimony indicated that children before the age of five are engaged primarily in activities of eating, play and sleep. During this time, it is very rare that they will do any sort of work – fieldwork, housework or otherwise. At the age of five, however, all children go to school. Since mothers are often occupied with foraging, fieldwork, housework and cooking – children’s play is often looked after by an older sibling or grandparent. One noticeable exception to this trend (referenced to Didi) is that certain children with no older sibling/grandparent are tied up and left locked in at home. In other rare instances, young children may end up accompanying their mothers to work.
In terms of hygienic practices, though there are obviously many local variations, a general picture of hygienic practice among pre-schoolers can be established. According to villager testimony, it would appear that children bathe quite often. In the summer, bathing occurs once every one to three days. In winter, bathing frequency decreases to once a week or less. All villagers have heard of soap and say that they use it regularly for bathing. Bathing of young children often takes place at open water sources (i.e. not in the house but from the source; the artificial pipes or natural spring where water is collected) and in collective groups supervised by an older sibling or mother. If soap is unavailable, there is mention of the use of mud or ashes.
In terms of washing hands and face, it is the villagers’ general testimony that children do this routinely when they get up from bed. There is mention in some villages that children wash hands after going to the washroom and before eating, but this is not the general case. When they do wash, children may or may not use soap.
In terms of brushing teeth, this practice varies widely from village to village. Brushing takes place at most once a day when children get up from bed. There is usually a proportion of children who do not brush teeth. Those that do brush their teeth do so in a variety of permutations. Some brush with their fingers and toothpaste, some brush with toothbrush and toothpaste, and many others brush with the twig from the timru tree.
Laundry is done anywhere from every time children bathe to once a week. Soap is generally used, and children have about 2-3 changes of clothes per wash. Clothes sharing among siblings or other children is common.
In terms of sleeping practices, it is important to note that the number of children in a family can range widely from 3-20. In almost all cases, the children sleep altogether on the floor in a room in the house.
In examining the names, perceived aetiologies, and treatment of hygienic disorders affecting children, certain broad trends can be established.
Our first difficulty was in distinguishing scabies from ringworm and discussing them with villagers as two separate disorders. While one source acknowledged scabies as coujali and ringworm as daal – all other sources could not distinguish between the two and discussion usually ended up being centred on coujali (scabies). This fact was confirmed by Didi, who mentions that the general education level on hygiene in the area does not make a distinction between scabies and ringworm since both are itchy, rashy conditions occurring on the skin.
The villagers recognize Scabies (named coujali by locals) as a condition that is characterized by itchy red rashes on the skin, especially around the knuckles on the hand. This condition is very common, by both admission of the villagers and by cursory visual observation of village children. Unfortunately for the villagers there is little to no conception about why scabies occurs. Oftentimes they had no idea why scabies occurred. In the rare cases where an explanation was given, reasons for scabies included dirty water, or excessive environmental heat. In addition, with the exception of one village, no precautions are exercised to isolate afflicted children or to make extra effort in cleaning clothes, etc. Moreover, there is not any evidence of awareness of necessary precautions to isolate such problems. In terms of treatment, most people answered that when the situation becomes serious [bloody rashes, excessive scratching in public (perhaps thus violating the cultural norm), secondary infections indicated by pus becoming apparent, or – these conditions indicating “seriousness” were presented by Didi] they go visit the doctor (see discussion of the definition of doctor towards the end of Summary of Findings). Otherwise a variety of home care remedies are exercised, including purchase of patent creams from the market (~25 rps. and only if the family is relatively affluent) or washing with water. As mentioned earlier, of all the sources we interviewed, only one recognized coujali (scabies) as distinct from “daal” (skin fungus or ringworm). Note, however, the source did not identify “daal” as due to fungus. He simply noted that the “daal” condition is different from “coujali”. His perception about the cause of ringworm was that it was due to impurities in blood, water and/or soap. The treatment prescribed by this source was to use burnt coconut shell and mixed with mustard oil to form an ointment.
Headlice (known locally as Jou) is another hygiene disorder that villagers readily acknowledge as a common problem among pre-schoolers. The villagers recognize that headlice is caused by the little lice bugs in hair and that it is potentially contagious. Regardless, afflicted children are not isolated from each other, nor is there effort to contain or pay especial attention to the washing of clothes. More importantly, there is no evidence supporting awareness by villagers to take such precautions. Treatment of this condition predominately centres upon use of a special fine toothed comb to “pick” out lice and eggs. One source mentioned the use of a chemical powder that can be purchased at the market.
Eye infection (red eyes, pussy eyes) is another common affliction affecting the pre-schooler population. Perceived aetiology and treatment vary widely from village to village. Perceived causes include dirt, and excessive environmental heat. According to villager’s testimony, this condition is apparently more common in summer than winter. Treatments include: antiobiotic drops purchased at the market, use of tumeric solution applied to eyelid, a plant “kinkora” is cooked and squeezed into the eye, raw “haldi” is rubbed on the eyelid, or a grass named “kooja” is applied to the eye. Serious cases of eye infection are brought to the doctor. There is also mention of a condition “auk agiey” that is characterized by the pupils going white and subsequent blindness. Unfortunately, as we have realized in retrospect, we had not thoroughly explored the meaning of “serious case of eye infection” nor did we ascertain whether “auk agiey” was considered a form of eye infection or an entirely different problem.
Ear infection (watery ears, smelly pussy ears) is another condition common among pre-schoolers. Again treatment and perceived aetiology vary widely from village to village. Explanations given include: pus leaking from the brain, dirt in ears, impure water slipping into the ears, and excessive environmental heat. Treatments include patented antibiotic drugs, mustard oil in the ear, olive oil in the ear, cold water in the ear and or cotton (q-tip?) cleansing. Serious cases are brought before the doctor. Again, we did not delve thoroughly enough into the meaning of a “serious case” of ear infection.
It is important to note what is meant by the term “doctor” when villagers bring serious hygiene disorder cases to a “doctor”. With the exception of one village which had an allopathic practitioner ˝ km away, patients are usually brought by bus or jeep to private practicing doctors in Gunsali. The doctors at Gunsali may or may not have formal qualifications to practice medicine (some practice homeopathy, some allopathy, ayurveda, etc), and Gunsali averages 20-30 km away for most of the villages we visited. The cost for this trip and subsequent diagnosis and treatment can be considered prohibitive by most RIMVs. In no interview did villagers mention bringing patients to the PHC – primary health care centre ( the heavily subsidized, state run institution).
Other conclusions can also be drawn in relating village context and implicit visual observations with the interview answers obtained. Such relationships include how villages of lower caste generally had children that were clearly less visibly hygienic than children from higher castes. Many children of lower caste exhibit scabies on the hands, are often barefoot with deformed toenails, and looked less clean (dirt on skin) and had clothes which were more worn. In addition, it is noted that it is usually the more affluent sources that will make mention of ever buying patent medicines from the market. This is indicative of a potential issue of medicinal accessibility. Other noticeable hygiene related observations include the pervasiveness of running noses – many times, this symptom was so severe that two white stain lines ran from each nostril to upper lip. The attitude towards runny noses can be described as utter nonchalance as children and adults do not bother attending (wiping) to it. A potential implication of this is that the villagers are unaware of the runny nose as being a sign of infection or source of further contagion. In addition, there is a lot of biting nails and of chewing of fingers among young children. This could potentially be a mode of transmission for worms or other gastro-intestinal disorders and thus deserves further research attention. On a more general note, there is noticeable segregation in play and company of female and male children even at the pre-school age. Implied in this is the early development of gender roles in the RIMV culture.
On Creche /Balwaldi or Day Care centres
Of the six villages visited, only one village has a day care. As iterated earlier, the pre-school children’s daily itinerary consists of eating, play and sleep. However, some of the children of Gauthi attend pre-school. The pre-school (Anginvari) is for children 3-5 years of age and runs everyday except Sunday. The school is run by women who receive their training at a development office. The school runs for two hours (8-10am) a day and they learn such things as brushing teeth and washing hands. In addition, songs are sang, cookies are distributed and prayers are prayed. The “school” consists of 2 teachers with a 35:2 child:teacher ratio. The teachers visit the houses of children to bring them to the day care; not all children in the village attend, different children may attend each day.
Two supplementary sources, the Primary Health Care Centre (PHC), and Didi of Jan Vikas Santhan (JVS) were interviewed in developing a broadened health perspective on RIMV pre-school hygiene.
PHC:
According to joint testimony by the pharmacist, midwife and optometrist staffing the PHC, incidents of Eye infections, scabies, ringworm and headlice are reported to the midwife serving the area. The cases are then brought to the PHC where they are treated for free by the staff on duty (on the day we visited, the pharmacist was in charge). The PHC organizes educational programs that educate village women on hygienic practices. Such “clinics” are held once a month at a different village each month. The selection process used to determine which village will receive the presentation on hygiene is NOT according to need, desire, epidemic, etc. We were unable to conduct a thorough, in depth interview due to: the numerous varied personnel we were interviewing; that the pharmacist did in fact have an agenda of showing us around; constant interruptions since the personnel we were interviewing were on duty; and time limitations. As a result, the interview we conducted was mostly improvised and unstructured. In addition, it is important to note that in this state run health institution, on the day we were visiting at least, there were no doctors and the pharmacist was in charge of seeing the incoming cases.
Didi @ Jan Vikas Santhan NGO
Didi is the secretary of JVS, and thus has knowledge of JVS projects and of the health practices of villages in the region. A structured interview was constructed prior to our encounter with Didi.
According to Didi’s testimony, the PHC plays almost no role in the average villager’s health care. The PHC “downloads” (words used by Didi) responsibility to educate villagers on hygiene and other health issues onto NGOs. In addition, she has not ever heard of the PHC conducting educational programs for villages. Furthermore, the majority of villagers do not go to the PHC, they often go to private doctors (by this – it can be allopathic, homeopathic, ayurvedic, etc – formally qualified / not formally qualified) The villagers distrust the PHC as it is often short on resources and expertise (staff and medicine shortage).
For example, the PHC recently conducted an eye check up camp in the area. The PHC staff member arrived at 1 pm when he was supposed to be there @ 10 am. He only had 9 suitable injections when there were approximately 40 people that required the treatment.
Looking into JVS’ work, it is revealed that they do not conduct any special clinics or projects oriented towards hygiene for villages. Instead, meetings are held discussing importance of hygiene and “the how to’s” of hygienic practices to village women wherever JVS has an active project in a village. The curriculum presented is very basic and method of transmission is through literature from Unicef and posters and books that JVS makes. In terms of effectiveness, Didi mentions longtitudinal, sustained discussions are necessary to effect change. Often times, no understanding or change in practices occur after one presentation. She does say that she notices improvement (by subjective observation) of hygienic practices in villages where “hygiene programs” have been sustained, and a continuous dialogue has been established between the village and the NGO.
Didi mentions that villagers do not know of any distinction between ringworm (fungus) and scabies (skin mites). As both are itchy skin conditions that involve rashes, they are often conceived of, named, diagnosed and treated in the same manner.
In explaining the villager’s attitude towards isolation of pre-schoolers with such conditions as scabies/headlice/ringworm – Didi explained that isolation is not exercised due to the high priority given to community, family relationships and general loyalty. Thus parents will not isolate affected children from themselves, siblings or other children. In addition, Didi also explained the lack of urgency in treatment exhibited by villagers. As conditions of scabies/ringworm/headlice are in fact very common, and the resources of the villagers (time,finances,etc) , medical attention is rarely sought until the condition becomes serious. For example, for scabies, treatment is sought only when itching becomes unbearable and/or secondary infections or bleeding of rashes occur. This would explain the inconsistency between how villagers say such conditions are treated as soon as they occur, yet when we observe the villagers attending the meeting, many exhibit clearly visible signs of scabies and they do not seem to be seeking any attention for it.
Didi mentions “bare feet” as a major hygienic health problem among pre-schoolers. As sandals are often viewed as luxurious frills – children are not encouraged to wear sandals. Didi states that this opens the children up to numerous common conditions including fungus, infection and tetanus.
Didi also mentions the widespread use of “oojah” doctors – special spiritual healers used in villager’s day to day misfortunes and physical ailments. She mentions that villagers are hesitant to discuss such things with people with Western educational backgrounds, thus we never heard testimony about the “oojah” doctors from the villagers themselves.
Finally, Didi states that hygiene practices cannot be judged or remedied without considering the wider context of Indian women life. Didi recommends more attention and study given to women’s health and lifestyle issues. As the primary care giver of the family, women are ultimately a deciding factor in level of hygiene in the family (number of laundry, baths, cleaning of house, utensils, educating children etc) Unfortunately, as women are over-burdened with many responsibilities crucial for survival (cooking, foraging, water fetching, agriculture) – hygiene is not a priority. According to Didi, it would be naive to believe any real changes can be made in hygienic practices without first addressing women and making changes in their lives.
Interpretations and impressions:
In examining the above data, conclusions with consideration of wider context, certain aspects of the perspective formed must be highlighted and critiqued. First of all – at the individual village level, it is clear that the degree of hygiene (evaluated by general observation: % of children with scabies, % of children wearing sandals, quality of clothes, general cleanliness, etc) is very much affected by caste of the children interviewed. Those children of villages of higher caste clearly exhibited a higher level of subjective visual hygiene. Thus, the social context of hygiene must be considered in discussing village hygiene.
Secondly, it appears as if the PHC, the 1st level of state run health clinic/programs, plays a small if not completely insignificant role in the health care of RIMV. Didi mentions distrust of PHC by villagers, and villagers rarely (if ever) mention the PHC as a place to go when getting treatment. Instead, if people seek medical treatment at all, it will be to attend private practices in Gyansali. Compared with the information we gathered from the villages, the PHC interview data revealed some inconsistencies. According to the villagers, eye infections, scabies, and headlice are treated in the village (w/ home remedies or patent medicines); only serious cases necessitate travel to Gyansali. Among villagers, there is no mention of using PHC trained midwives for diagnosis or treatment – nor is there any villager that said they sought PHC for treatment. The PHC’s testimony, however, is that all such cases are brought before the area midwife, and then referred to the PHC for treatment. The impression that the PHC was presenting (in terms of the neatness, tidiness and inconsistencies of their answers to our questions as compared to the villagers) leads us to believe that they were giving an over-simplified version of hygiene health care that indicated everything was under control.
Another matter of concern is our methodology and resulting bias in answers. One problem we encountered early on was the accidental asking of leading question which would cause the villagers to “clam-up” or give answers we were looking for. E.g. we ask about a bunch of question related to scabies, then we ask about bathing, and laundry practices and whether they use soap. This line of question produced uneasiness, and we believe the intrusiveness of this approach could lead to biased answers. I.e. the villagers do not want to look uninformed of hygiene matters – and thus will answer they do use soap and do bathe daily when they may not. (remember that the villagers do not know the cause of many of the hygiene disorders they are afflicted by, sudden questions about bathing practices can seem insulting at worst, from left field at best) Furthermore – a bias moving in the opposite direction can also sometimes occur. Instead of villagers satisfying researcher demand characteristics to proove self-worth, villagers would and could underplay their knowledge of hygiene or access to resources for ulterior motives. This point was brought up to us by Saji Kumar, our guide and person knowledgeable in the field (an associate of Manthan Associates, a developmental NGO based in Dehra Duhn). He mentions that since we are gaining access to villages through our NGO host JVS – this privileged access can also be a source of bias. Villagers know JVS is a developmental organization with success in the area. Villagers, thus, may underplay their resources (water) in order to solicit sympathy or developmental project from JVS. This seemed to be exhibited in the Ghauti village field visit where villagers continued with determination to blame their lack of water for all problems and stressed this point repeatedly to the point of being beyond reason.
Furthermore, as Didi pointed out, the fact that we ask and pose questions as educated people (university students of the first world) also bias’ interview answers from villagers. Not one villager at any meeting in any mentioned the use of spiritual “oojah” doctors in diagnosis or treatment of hygiene disorders. Didi, however, states flatly that the belief and use of “oojah” doctors is widespread. Her explanation for the villager’s silence on the matter is that the villagers know that educated people would not understand and only end up trying to talk them out of something they firmly believe in. Therefore they omit such testimony.
Much work still needs to be done in order to develop a perspective on pre-school hygiene in RIMV. The 1st recommendation pertains to methodology. This is to establish a proper question set that minimizes demand characteristics, is culturally sensitive to the villagers (use of readily understandable vocabulary, not intrusive or ignorant of local sensibilities), and contains an open approach to limit bias and not lead villager’s answers. Secondly, this interview form must be consistently applied if data collected at each interview is to be comparable. In addition, by doing this, although bias maybe built into the question set, at least it would be consistent bias. Currently, the data obtained is a combination of different question approaches. This makes it hard to tell if differences in answers are due to actual real differences in the villages or differences in questions and questioning. At this time – we are uncertain. We also believe further research into the actual hygiene disorder conditions themselves may yield more pertinent questions. After that, the design of a successful open interview question set will rely on common sense, perhaps more trial and error, and sensitivity.
As for the questions themselves – in addition to being open ended – e.g: “what do you wash with?” As opposed to, “do you wash with soap?” – we also recommend that the terms in the questions be clearly defined for villagers. In one village – there were wild inconsistencies in terms of answers to how many baths children took. In retrospect, we believe that one source may have intended bath as playing in the water and another source acknowledged that a bath was more than play in water but included supervision and cleaning agents. Thus, this could plausibly explain how one source said children bathed everyday, and another said one every three days. Conversely, maybe one family did bath their children everyday and another did not. The specificity of terms and details pertaining to actions cannot be stressed enough. For instance, in retrospect, we were not very specific with what is meant by washing hands. While we did ask if they washed hands or not, we did not find out such details as where they washed, with what water source/cleaning agents, with whom, where did they dry their hands, etc. Finally, it is important to have the villagers clearly define their responses to questions. Often times we accepted answers such as “we take the children to the doctor when the infection becomes serious”. In accepting this answer, we fail to obtain crucial information on what is meant by the “doctor” or in what situation is the infection considered “serious”.
One area that clearly deserves further attention, either by the hygiene group or perhaps the gastro-intestinal group is the problem of worms. Worms, or joukou as it is locally known, is very common according to testimony by at least one village source, and by our guide Saji. The infection rate of this disorder is apparently very high. From our informal interview with Saji, we gleaned that the symptoms include stomach aches, possible diahrea, and in more serious cases: worms leaving the body through the anus or vomit, and fever. Dr. Sacchin, another guide, has said a symptom of this disorder is white or colorless patches on the face. From visual observation, this apparent pigmentation problem is quite often. Although I cannot confirm that these people have been infected by worms, if indeed white discoloration patches on the face is a symptom of worms, then even by visual observation, this condition is quite common.
Other potential areas of study include the further research into the prevalence of runny noses among children and of the practice of biting nails and chewing fingers. Both can be modes of transmission for disease, and the lack of attention given to hygienic behavior (of wiping noses and discouraging finger biting) may have implications on the health of RIMV children.
In terms of content, we regret to say we did not ask the villagers the effectiveness of the treatments (home-remedies, patent meds) that they themselves employed. We also believe questions pertaining to whether there is a change in diet of affect children, and if so, what changes are made could yield interesting data. Such information on diet may also illustrate lay beliefs RIMV potentially have regarding the hot/cold humoral qualities of food and body.
In retrospect, another large shortcoming of our study was not properly identifying the herbal remedies used by villagers. We now have local names for certain remedies, and what they are used for. However, without an actual sample, or having the name be translated into English or its pharmacalogical properties explained by someone native to the land (whether they be lay beliefs of properties, or better yet, an expert source that can scientifically identify the substance and its properties), we cannot tell if such treatment is appropriate or effective. Furthermore, it would have been beneficial if we obtained more information, a sample or even the packaging, of the patent medicines employed by RIMVs. Information such as: cost, composition, method of use, and brand/make of medicine could yield interesting data.
In terms of the projected goal of the health care manual, it would be beneficial if researchers participate or sample in the “education” systems currently available to teach hygiene and about hygiene disorders to RIMVs. By looking through current literature and sitting on discussions in the villages (or presentations made by NGOs such as JVS), insight might be gleaned on what types of language, illustrations, examples, etc are effective and culturally sensitive in communicating such issues. This information can of course be then incorporated into the development of a successful health care manual.
In addition, further sources – in terms of other NGOs and another in depth structured interview of the PHC – may help yield a clearer picture of the PHC’s role in rural Indian mountain health. As the PHC is government run and theoretically the first line of defense in providing cheap, universally accessible, and effective service – its operations need to be further scrutinized.
Finally it has been mentioned that villagers approach a wide range of private doctors for treatment. These include Bengali, Ayurvedic, “oojah” doctor/priests, homeopaths, and allopaths; all of which have varying degrees of qualifications. These doctors should all be sought out and interviewed to further develop a holistic perspective on RIMV health.
Last of all – speaking with ore experts in this field, example being Didi – the secretary from JVS – would be highly beneficial. Their ample experience in this area and its people yield unique perspectives unattainable by our own 20 day stay in this area. For example – Didi mentioned the prevalence of “oojah” doctors in the area and in the importance of women’s issues as a factor in hygiene. Such insight and information can lead to further studies and the creation of a better more extensive interview question sets (for villagers) that can perhaps provide even more data to develop a holistic health perspective. Clearly, longtitudinal research would be very positive, but as we do not have the resources or perhaps even intent, to commit to such research, the next best option is to interview people that have done longtitudinal research in the area.