SIHI2001 Final Report Part 1

Student International Health Initiative

India Field Research Write Up Part 1

This following document is an informal report on an experiential learning course that was developed as a joint project between McMaster University’s Student International Health Initiative (SIHI) and Manthan Associates, Dehra Dun India. The objective of the six-week course was to develop a cross-cultural understanding of major health and developmental issue of rural Garhwal, India.

The course was designed for a group of 14 students from McMaster University. Upon arrival in India, the students stayed in Dehra Dun City for ten days. The purpose of this portion of the trip was to allow students to become familiar with north Indian climate and culture. Several small field trips and small group discussions with guest lecturers, gave the students and facilitators the opportunity to begin relationships and dialogues. The second portion of the trip took place in the rural mountain regions of Garhwal. The group of 14 students and 2 facilitators stayed with Jan Vikas Sansthan, a non-governmental organization working in the region, for a period of 20 days. This time provided the opportunity to build bridges of understanding among the different cultures and communities involved in the course. Students were given first hand exposure to the reality and details of development work. The SIHI group was also given the chance to conduct research on the health perspectives, beliefs and situations of the people of Garhwal. The final portion of the trip was a 10-day trekking experience in the mountains. This trek was very valuable as the SIHI students came to understand the beauty and the challenges of living in the climate of the Himalayas.

Reflections: Members from last year’s group were requested to submit a short reflection (approx. 1 page). The topics of the reflections are open-ended. Examples of topics may be lessons learned, suggestions for next year’s group, creative writing pieces etc.

Modules: All the separate modules that were developed by the 2001 group will be included in this section. Specifically the module topics include, Common Illnesses (Diarrhea, Pneumonia and Intestinal Worms), Childhood Hygiene, First Aid, Nutrition, and Immunizations. An effort was not made to standardize the format of these modules. The modules consist of field research notes, observations, and limited analysis.

Cultural Sensitivity: This short section will be most useful to future groups. It outlines the necessity for cultural sensitivity and appropriate behaviour in different regions in India.

Conclusions: This section consolidates the write-up and provides a basis for next year’s research objectives.

Personal Reflections

The following section is a compilation of 6 reflections submitted by various members of the SIHI 2001 India group. These reflections discuss various aspects of the group members’ experiences. This may shed insight into the satisfactions and challenges of taking part in an experience such as this.

Jonathan Chang

When I think back to those six weeks in India I remember the transitions and changes we went through most clearly, like moving from Dehra Dun to Chirbatiyah or from Chirbatiyah to the trek. But there weren’t just changes to my external environment that I noticed, there were some internal happenings. I tried talking to people about the trip when I got back, but I didn’t know how to put the experience in words. I’d always say, “I have to think about it. I need time to absorb everything that happened.” But still, I don’t understand the impact that this trip will have on my life or how it has impacted my life. I have adopted yoga and meditation and I still keep in touch with Sachin (he gives good advice)...and I do find myself being swayed by Eastern spiritual philosophy. If anything, the trip gave me time to reflect on what I want to do in life, even though much of what I thought I no longer believe (especially about development work). There are some ideas, however, that I started to formulate and learned from the interactions with members of the trip and from the time alone. One of my goals in life is “self-realization” despite the ambiguity of the term and its cultivation. On the one hand this trip taught me a lot about myself. But what else?

We saw so much I can’t describe it all in a short reflection. Sachin and Saji created the perfect learning environment. It all depended on the individual to make the most out of it. We were exposed to health care in the urban and rural areas, we even visited ashrams, a charitable hospital, a leprosy colony, PHCs, a Bengali Doctor, an NGO in the mountains, Gujher nomads, and so forth. The day we went to Chirbatiyah is imprinted in my memory. Stepping out of the Tata Sumo into the cool fresh mountain air (and after a scenic drive that curved up and up through terraced fields), seeing quiet village children curiously looking at us, and thinking to myself “I can’t believe this is going to be my home for three weeks!!” I couldn’t stop smiling. I remember hugging a couple guys on the trip and feeling this pure excitement and joy. Right away I idealized the village. It’s so easy to do, especially as a traveller -- we weren’t really “development workers” yet -- when you only see the superficial aspects, such as the solitude and isolation with green mountains all around. I romanticized the place even more after going on a morning hike the following morning: once we stepped off the dirt driveway to JVS a herd of goats passed in front of us through a thin mist. Slowly, through our exposure to village life, I didn’t see the place as a paradise. The first village we visited, after falling into a bush of stinging nettle, I was able to sit in one of the interviews with the women (the guys were touring the village, the girls conducting the interview). I heard their way of life and how difficult it was (in comparison to the West) and later we also saw women involved in this hard labour (like collecting firewood in the morning). I like seeing how other people live. It feels kind of exploitive, but you can learn so much. And with this new knowledge you can use it to change your way of thinking . It challenges you to understand things from a different cultural perspective. From these people I learned the importance of community, something which we at home don’t have and also I felt that everyone I saw seemed so strong...I wished, however, that I could speak the language. Without any ability to communicate with people, aside from smiles and hand gestures, I felt silent and still ignorant of the culture around me. But I had such a strong desire to learn...

One of the most memorable experiences of the entire trip was the 10 day trek in the Himalayas. It was a good bonding experience and a good way to see the diversity of the region.

Here are notes from a piece of scrap paper I wrote during our trek (I began to romanticize the place again):

- image of heavenly goats, creating an idyllic image of a life I would like to live (a goatherd that is)

- at a Gujer’s hut where Sachin is negotiating a drink for us, “30 min” from the village...a white goat chews on grass. A wood hut with a stable. A baby’s cry.

- I walked then ran away from the group in a clearing with empty Gujer hjuts. On a high point of the clearing a deep valley cut through my vision. Villages in the distance with terraced fields, cow bells ringing -- buffalo milk in a bottle, slung over my shoulder-- birds singing, and a river flowing, sounding like a waterfall. Now storm clouds hang over me, gray above, light far away. A termite bit my hand as I tried to climb a dying tree. I jumped off.

- a crow landed on a small birds nest. The small bird in swooping downward arcs, going back and forth like a swing, scared away the crow. At first it looked like a game or mating ritual.

- I’m sitting on a foothill of the Himalayas staring at more hills and peaks and mountains, with all these sights and sounds, filling me with peace in my solitude.

- I walked to the Gujer’s hut with Vikas. A stable and rooms, made of wood and stone, fresh cow shit around on the ground, but nobody there.

- sitting at the bottom of the hill, in the valley by a fast stream. Pushed my head under a current of water, flowing over rocks to a lower stream.

- woke up at 2 am to a thunderstorm. Tent got wet. Cold in the morning. Rolled in a ball and held knees to chest, feet too cold to put on the ground, ground too wet and cold in the morning. Socks wet, same with shoes. Feet went numb but warmed up in the sun and while walking over green rolling pastures on our way to a Gujer’s hut to get tea. Could see snow, at least glimpses of it behind white clouds. Cows grazing on fields ahead of me, buffalo, gray with horns. Some brown with white tufts of hair on their heads. Watching the women milk the cows, clouds all around.
June 6th - walked on a green pasture. Waited with cows. Small areas enveloped by their chiming bells

- at a peak of 13000 feet white horses graze on an expansive pasture, hidden in the clouds

A note from my journal, written on the plane back to Canada (the day after visiting the Taj Mahal):

Do you remember running on the red-hot stones to the Taj guesthouse?, feeling the sting of heat on the soles of my feet as I ran, ran in all freedom of movement, wildly clutching my camera as it hit my side...

Farah Ramji

The 8 weeks spent in the Himalayan regions of Garwhal and in Dehra Dun were the best times of my life. This experience ended up being the most exciting, thought provoking, educational and challenging experience of my life. First off, this trip allowed me to learn more about the Indian culture and customs which was really important, as my ancestors rooted back from India. Also this trip was more than an educational excursion. To me the spiritual aspect of the trip, performing yoga and medication was able to bring peace to my mind, and enabled me to discover myself. Having now had first hand experience with yoga, this is something that I continue to perform every now and then. Being involved with many developmental organizations I have always read about poverty existing in many areas of the world, however during this trip I was given the opportunity to come in contact with it face to face. Interacting with the people of the villages gave me a chance to see that primary health care and immunizations are a world away, and if it is made available it is not accessible to all families, as it is very costly. Seeing this first hand, I also realized that although there is always room for more developmental work to be done by international organizations, it seems that their way of life is a lot different from ours in Canada. At times it was even difficult for myself to understand why they did things in a certain way and vice versa. For them it seems that over centuries the people of the mountains have become adapted to their lifestyle. Experiencing living under harsh conditions during monsoon season, as well as walking at high altitudes for many hours in order to get to a market made me frustrated at times. Now I realize that this is the type of life these people have live with every day of their lives. I also realized that it is easy to talk about living the life of another human being, but when you actually have to live the life it is not that easy. Observing the lack of educational opportunities available to the youth was sad. At the same time no matter how depressed theses people were they always had a smile on their face. From this trip I learned that it is important for us individuals from the western society to appreciate life more and not take things for granted.

It was in the Himalayan mountains where I learnt the true meaning of challenge. I realized that so often in our society we are protected from being challenged because it seems like such a hard thing to face. As part of the 10-day trek there were many times where we camped out in conditions that were not ideal for me. Walking up the mountains to high altitudes there were many times I felt that I would not be able to reach the peaks after having walked for 6 or 7 hours. However the beauty of the mountains around me seemed to make the cold and rain worth while. This was something I had never experienced before. My ability to persevere and the fact that I was determined to experience this adventure, unable me to be a successful trekker on this trip.

To next year's group, be prepared to experience incredibly intense 8 weeks. Try to absorb and take in as much as possible during the project, and go with an open heart.

Neilesh Soneji

It has been many months since I last stepped foot on the land of the Garhwal Himalayas. I flip through my photo albums and reminisce about the beautiful times we shared in India, within our group and with all the individuals we met along our journey. I vividly recall the panoramic views of the mountains, bus tops, trekking for hours with no particular destination in mind, feeling totally enriched spiritually, totally alive. Now I am sitting in my Hamilton home, listening to the buzz of my PC in the background, watching the rush of cars along Main Street through my window - and well - it just feel ironic. At times I still question how these two realities can exist in chorus. But as I think on about the comparisons and contrast of this life and that, I believe more and more that it’s diversity which makes the music.

If I were asked to convey one of the lessons learned throughout our 45 day journey in Uttaranchal, it would be the importance of an open mind during an experience such as this. I can trace this lesson all the way back to our frantic preparations in Hamilton prior to departure. Group expectations were building, and preconceived notions were forming, all amidst the growing ambition of producing a health care manual by the end of our trip. It seemed like an appropriate project at the time. We would land in India, figure the region out, and conduct our research. Before we knew it, the health care manual would be produced and the people of Garhwal would be left with a resource through which they could improve their own standards of living. How perfect a plan, how simple a process…how ignorant a conception!

First of all, the nature of development in India quickly became apparent to us as we were exposed to the diversity of life in this nation. Garhwal itself is so vast with Garhwali, which is one of the 1000 dialects of India, as the spoken dialect of the people. Wholly! And as we tuned into the realities of life and culture there, the political organization of the state, the beauty and challenges of rural life, and the numerous facets of development work in the NGO field, I felt like a child lost in a world of opportunities.

There was so much I wanted to experience, and so much change I wanted to influence for these people, but no basis upon which to orient myself. These feelings of confusion and inability to make a difference even made me question the validity of our visit. But as our trip carried on, I realized that I was being closed-minded. I was only perceiving ‘growth and development’ through my preconceived ideas of what the trip’s goals were…a health care manual. In reality, there was so much more to experience and appreciate in an environment such as this.

As a result of this transition in my thinking, Garwhal became more than a place that I was meant to ‘uplift.’ It became a really meaningful place for me. I began to see the lifestyles of the people as they really were, including all the challenges of village life, balanced by the serenity and beauty of the environment. The people of this place touched me and I will never forget the kindness that was showered upon us. I recall one trekking day when we had just set up the tents and the rain began to poor down on us. By this time we had run out of food. The googer people of the region kindly welcomed us into their homes and fed us warm rotis and milk to sooth our hungry stomachs. It was these types of interactions which I recall most fondly. In retrospect, I believe I was only able to really enjoy these particular moments through having an open mind.

I realize now more than ever, that the bridges we made during our time in that region of the world are meaningful and important, if not for any other reason than the openness with which I can perceive the world now. I appreciate all that I learned from the people in India, such as Dr. Sachin and Saji. One day I plan to go back and visit. Some time, some how. I wish next year’s group all the luck in their endeavours in India. I am sure your experiences will be phenomenal.

Shaheen Bhaloo

My experience in idea was one of a lifetime! Rarely does a day go by that I do not think or remember an aspect of my trip to India. Usually something I do or say will trigger my fond memories of Dehra Dun, Garwhal, the day trips, the Taj Mahal, the food, the culture and most of all the people. When I look back to when I was preparing for the trip, I did not know what to expect and I did not even know what I was getting myself into! I was unsure about what to expect, nonetheless, feelings of anxiety and at the same time excitement rushed through me. Luckily, I was with a wonderful group of people that helped each other out during the difficult times of the trip and made each other laugh and enjoy ourselves in an environment new and unfamiliar to most of us.

Now that a group of 14 McMaster students have gone on the trip, experienced the Indian culture in 45 days, and returned home safely and most of all happy, I would like to help prepare those students who are going to go to India this summer as I am sure I could have used some advice and guidance when I was going.

Firstly, it is important to keep in mind the goal and purpose of the trip. Last year we left for India with the intention to come back with enough information and field research to complete a Health Care Manual. However, we realized as the days went by and the more experience we had with guest speakers and trips that this was not going to be feasible. It is extremely difficult to go into a new country, learn of its cultural norms and developmental issues, and then come up with a way to improve the health care system by ultimately producing a Health Care Manual. Instead, it is crucial to be open minded, and consider this trip as a learning experience of how developmental issues, especially in the health care are dealt with in India. Understanding India’s cultural norms and behaviours in relation to health care is also very important. At the same time, as much as you learn from the people you meet, they will learn from you about the Canadian culture and how we live, making this a cross-cultural experience for both sides!

Secondly, one of the biggest barriers of doing health care developmental research in a different country is language barriers. In Dehra Dun, Hindi is the language most commonly spoken. I would suggest that if you do not have any knowledge of Hindi, then try to learn some basic sentences, enough to greet and perhaps have a basic conversation with someone. I speak Gujerati (somewhat) which is an Indian language and although there are similarities to Hindi, I still faced difficulties in communicating with people. Many times I wished that I could ask people how their day was, or ask children what they like to do for fun, but with the lack of basic Hindi skills that I had, I was unable to do so. If these communication skills are not learned then it is hard to interact with others and get the real insight to these individual’s feelings.

Another important thing to keep in mind are gender issues. Some of you may be aware that India has many gender related issues that need to be addressed before you leave for your trip. To fit into the culture, both women and men should wear their appropriate cultural outfits (shalwar khamis for women and khurta for men). It is important for women to be decently covered at all times. In addition, it is not appropriate for men and women to be talking to one another or hanging around one another (all the time). Naturally, this may seem absurd to us Canadians, but it is something that we faced last summer, and should be considered more this summer. There are definitely times when it is okay to engage in social activities together, but it is crucial that you use your discretion! It is just being respectful to their culture and norms.

Lastly, get prepared to do a trek of your lifetime (at least for me it was)! The 10 day trek was absolutely incredible! I never imagined myself to be one to trek for so long, uphill, downhill, over rocks and grasslands, sleep in tents, and cook in the cold. I did not think that I would be able to handle all of this, but I surely did and I do not regret joining the group for one second! However, I would definitely recommend that you prepare yourself physically for the trek as I realize it would help if you are in good shape!! Definitely do not pass this opportunity to trek in the Himalayas, where you get to see ice snow peaks on the distant mountains of Nepal, meet no-mans on the way and experience the tranquility and peaceful nature surrounding you the whole time (only to mention a few things)!

Hopefully these pointers will help you immerse into the culture better than perhaps we were able to. I could probably go on about how you could make your trip an amazing experience, but in the end, you will learn as the days go by and come to understand the culture from you own experiences. Going so far overseas is an experience that you will never forget, whether it is a bad one or an excellent one. By preparing yourself mentally, physically and intellectually, you should have no problem make the trip worth your time and gaining an insight into a culture that is so diverse and rich!

Adnan Pirbhai

The real impact of the SIHI Project didn’t hit me until our group was pulling out of the driveway at the guest house in Dehra Dun, at the end of the forty five day quest. Having only recently returned from the final trek and with emotions and intellect numb from trying to process the experience, I didn’t feel ready to leave Dr. Sachin, Saji and Dehra Dun. And then it hit me: how does one prepare to leave a new-found family and home, unsure when or if one will ever return? I connected with the Himalayas in a way I never dreamed. I connected in the Himalayas in a way I never dreamed.

Himalaya. Immediately, the term conjures up notions of enormity and strength. Only until I caught a view of her actual snow peaked mountains unexpectedly through a clearing in trees while trekking through the lesser ‘hills’, did those notions secure a reality. At that exact moment, silence fell over all of us who were there, almost a testament to the immediate sense of respect and awe those mountains command, yet are still farther than they seem. But Himalaya was never cold to us. She was always warm. Warm enough to mother generations of nomadic Gujjars whom without second thought would allow us into their huts and offer strange visitors sweetened buffalo milk and rotis - feeding us like we were their own. Warm enough to leave us trails to and from the hundreds of villages throughout her hills, only to arrive at these villages welcomed like long lost brothers and sisters. Warm enough to provide us fresh water just when we needed it. Often leading us on treacherous trails, never once were those paths blocked. In fact, she taught us that the more difficult path would lead to a more breathtaking view.

Without coaxing, I endeavoured to walk every path in those three weeks of field research. One can’t help but succumb to the urge to learn all you can, in every way you can, with something, someplace, so new, so beautiful, so rich, so beyond any picture, unlike any dream. Like a sponge, one should take advantage of what is being generously offered. Leave familiarity at the guest house in Dehra Dun. Embrace a different way of life, a different culture. I knew I was there to learn. To connect. In simply attempting to communicate with the Jan Vikas Sansthan staff, I was connecting. I connected. Every evening, I grew closer and closer to that family. I was yearning to learn their ideas, their stories, their dances, their songs, their cultures, their lives.

Oh, to live in the Himalayas. In the villages, be receptive. Notice everything. Remember details. Write down your thoughts. By simply exchanging glances with shy school children, I felt like I was making a connection. I wanted to use every God-given sense to absorb all I could from and about the mountain culture. Open your eyes. Take deep breaths. And plunge into a culture that reminds you how lucky you are to be there, and how lucky you are to be here. I admit I sometimes forgot the real reason why I was there. Try to make a difference in others’ lives, but be aware that they will make a difference in yours.

I left my parents and siblings at the airport in Toronto confident that I’d be returning to them, God Willing, after a short time. What I did not know, however, was that I was about to embark on a learning adventure of a lifetime, where the biggest mountain range in the world, its people and its culture were waiting for me, with open arms, ready to make me part of their family.

Vikas Bhagirath

My 20 day stay in Chirbataya in the Gharwal region of Uttaranchal will always be remembered with fondness. There are many conflicting images that come to mind: the beauty of the land, destruction and poverty, the wonderful people and their culture and its changes.

When our group first arrived at the site of the NGO in Chirbataya a very spiritual experience occurred. All around us were green and yellow mountains with snow-white mountains in the distance. The air was cool and pleasant, and no mosquitoes! One could not help but feel surreal and many members of the group started to spontaneously pray in align with their own faiths. The terraced farmland scaling the mountains reminded me of the history of this ancient culture. Every direction could have been a postcard.

After a few days one realized that despite the picturesque surroundings there were serious health issues which made the inhabitants have a tough life. As is well outlined in the report there were numerous issues that lead to sickness and deaths. Caste issues and beliefs were firmly entrenched in the minds of most villagers. The lower castes had less developed villages than the higher caste villages. In some villages the castes were segregated. Lower caste villagers always sit on the floors in the homes of higher caste hosts. It seemed as though most of the people had idealized views of Canada, as if it was some kind of paradise and would question me about immigration matters.

What I reflect most about are the people in the villages and the beauty, elegance and wisdom of their culture. All along the road there were various makeshift temples which were erected to signify where someone died in an accident. Some of the NGO workers told me about horrible bus accidents killing dozens of people which were marked by temples mere steps away from the village we stayed in. One does not have to wander far from the road to encounter people of older times. Gujurs, who are nomads occupying the jungles in the area during the summer take their buffaloes along secret ancient trails. The story is that when the king of Terri-Garwhal’s son married the daughter of a king from modern day Afghanistan, as a gift to the Terri king a few hundred gujurs went to Terri with the bridal procession to supply milk from the buffalo’s. Hundreds of years later the gujur’s are still there walking in the jungles with their Afghani style turbans and nomadic lifestyles. I will never forget walking through clouds, seeing satellites race through incredibly starry skies, brushing my teeth in potato fields, dozing off while riding on the roof of buses and seeing white horses, buffaloes, sheep and sporadic huts where people lived and provided us with tea. At one village I saw a ceremony where a women was “possessed” by the spirit of her deceased husband.

As always the area is changing. The roads in the area were developed recently after the Chinese-Indian war where the Indian army could not move supplies because of the poor condition for travelling in the area. I remember Coca-Cola being sold in Chirbataya. I recall feeling like an arrogant, first world educated fool when interviewing villagers. I remember being asked how much I paid for my shoes if I converted Canadian money into rupees, and feeling guilty and lying. I remember the sense of community and family which does not occur in Canada. The hospitality of everyone we encountered was unbelievable and I hope future generations of student can enjoy this kind of opportunity.

Daivid Ng

We are filthy and coated in sweat. I have not changed my shirt or pants in the last ten days.... my underwear, I changed only once. - Lick my shirt! It is stiff and salty like a stale nacho, a product of my sweat baked into cotton by the Himalayan sun. In ten days, we had trekked over 80 kilometres of glorious mountainous terrain, crossed three mountain ranges and ascended a peak 13,000 ft above sea level. Tonight, we dine and reminisce over the exhilarating journey that we have just finished. As we sit to indulge in the meats and sauces laid before us, our guide, our mentor, Dr. Sacchin toasts, “Now that we have conquered our peaks, may we have as much luck and success in conquering our inner peaks.” That night, we all cheered the toast, and congratulated ourselves for the journey “conquered”. At the same time, the good doctor had presented us with a mental bauble - I asked myself, What was my inner peak? How will I conquer it? As I reflected upon my entire trip in the Himalayas, I came to identify my inner peaks as the internalized assumptions and biased thought patterns that have served to guide my way of experiencing other lifestyles and people. These internalized assumptions and thought processes impeded my ability to empathize, and to understand the way of life for other people, specifically the rural mountain people of India.

My ten day trek in the Himalayas was a “test” of mental and physical will. However, before this trek, I and fourteen other people from the Student International Health Initiative (SIHI) of McMaster University were members of a research team. The ultimate goal of this sustainable project (note - SIHI is currently sending a team to the Himalayas annually to maintain the project) is to assess the health status of rural mountain Indian people and construct a culturally sensitive/appropriate, allopathic health care manual that could be used by the mountain villagers. We visited, observed and interviewed local government health clinics, traditional non-allopathic doctors, women in the villages and non-governmental organization workers.

Over the course of the thirty days that I worked on the Health Care manual project, I struggled very had to explain or justify my reasons for working on the project. In doing development work, an implicit assumption I had formed was that since there were people here less fortunate than myself, I needed to “help” them. I suppose I was guilty of harboring some delusional grandeur that I would somehow be able to drop into the Himalayas for 30 days, share my knowledge and my willingness to work and have a significant impact on the health status of rural mountain Indian village people. However, such ambition was meant more to satisfy my own ego than to really “help” anybody. The ‘solution’ of providing Western based health care knowledge and practice to directly ‘help’ is overly simplistic, negating the realities in which rural mountain Indian villagers negotiate their lives. I realized that in growing up in the North American environmental, social and cultural context, I have internalized the dominant values and realities of abundance of high-quality resources, social organizing principles of equality, and science, its principles and practices as the “gold standard” solution to problems. What I came to understand along my journey, was that “helping” the rural mountain Indian villagers was really about being aware of the conditions of their lives, learning from their perspectives and implementing change that was contextually relevant to them.

It became very clear, very quickly that a viable Health Care Manual was going to have to be a LOT more than merely a Hindi translation of allopathic health care practices and treatments which would address common health problems experienced in the villages of the Himalayas. To begin with, most of the people could not read. Furthermore, and even more importantly, the environmental, social and cultural context in which people lived in simply did not permit an application of Western-based health care practices as we know it.

Many water borne illnesses such as cholera, and typhoid fever are unbeknownst to us because we have an adequate fresh water and sewage infrastructure in Canada. In the Himalayas, a woman can trek up to 10-20 km daily to bring home only one large container of fresh water. To exacerbate matters further, the quality and accessibility of the streams were often inconsistent. Thus it would be of little use to produce a Health Care Manual recommending the use of fresh water to clean, wash or bathe the way we do. A solution like this assumes water quality and availability similar to ours, and neglects the reality the rural mountain people live in.

Likewise, the social context in which rural mountain Indians live in is also drastically different. Infant mortality is relatively high in the Himalayas. In response to this, we asked a group of villagers what pre-natal care for the mother was like and how long the “maternity break” was. The village women laughed, their response was to the effect of, “survival in the Himalayas is difficult, everyday it is a woman’s role to venture out to forage for firewood, to bring home water, to labor on the mountain terraces for crop, and prepare all the meals. Thus there can be no break from work. Often, woman will work everyday like this while carrying the fetus for the full nine month term, give birth one evening and return to work the very next day!” In terms of cultural effects on health, although the practice I am about to describe could not be confirmed in the villages we visited, it is a well-documented phenomenon in cultures that believe in the “humoral theory” of food as practised by rural mountain Indian villagers. According to this cultural theory, all food is categorized as being either “hot” or “cold” in humoral quality. Many illnesses, including diarrhoea, are considered to be a result of an excess exposure to “hot” elements (including food and weather). As a result, treatment would preclude ingestion of any “hot” foods. Ironically enough, all Western based medicines, antibiotics, etc, are considered “hot” foods. Thus, when Western doctors prescribed “ORT” (oral rehydration therapy ) to combat diarrhoea, the compliance was extremely low, and thus people died despite having access to Western-based medical care.

At first, it appears relatively easy to write the Western health care practices to such problems in a health care manual. “Ensure ample rest time for maternal and pre-natal care, and always drink your ORT!” These solutions are based on cultural values and social realities that we have internalized and thus we would not question. Thus these solution make sense to us. However, these solutions as applied to rural mountain Indian villagers would, at the very best be ignorant, at the worst, it would be a crime of cultural imperialism. These simplistic solutions assume that the rural mountain society and culture are like ours and misunderstands the context in which these people exist. How does a woman take time off work when it is her socially inscribed role to provide for the survival of the family? How do people embrace ORT when according to their time-honored cultural tradition/logic, the practice of ORT would only worsen diarrhoea!?

As we, the group, came to realize this, we became less intent on the production of a Health Care Manual and more concerned with the environmental, social and cultural realities surrounding health in the Himalayas. In a way, this was difficult to accept. It was a tremendous blow to our collective egos that we would not be actively constructing a Health Care Manual but instead be seemingly relegated to the task of socio-cultural research. At the same time however, the realization that we could not fully crystallize and understand a culture in four weeks AND thus could not produce a culturally relevant health care manual was liberating. The new mandate to learn as much about the environment, society and culture around us presented us with the opportunity to fully see, live and know a different way of life. This experience presented us with the opportunity to critique and deconstruct implicit assumptions about the way we live in Canada, and think about how and why we assume this to be the universally-desired standard.

The challenges and struggles to understand and see clearly the way people live is not restricted entirely to normative assumptions stemming from North American life. I found that my attitude, informed by a comparative thought process in which I would compare my life at home with the way people lived life in the Himalayas to be also counterproductive. My attitude shifted between two poles, one of pity and the other one of romantic idealism. On one hand, in witnessing how the absolutely appalling and inadequate sanitation and hygienic conditions caused rampant illness among children, I could not help but feel pity. On the other hand, the seemingly uncomplicated and simple lifestyle set to a relaxed pace among the majestic Himalayan backdrop could not help but inspire idealism. I would think to myself, “These people have it going on!” Unfortunately, neither one of these attitudes permitted coherent, accurate understanding of the rural mountain Indian life condition. These people do not need my pity as much as they need my effort to understand their existence in a holistic context. I say this in response to the actions of one of my colleagues who would snap pictures of destitute dying people lying in the streets to show folks back at home. At the same time, engaging in the romantic idealism of this life invalidates their struggle for survival in tough mountainous conditions and the experience of poverty and illness due to a lack of resources. It is easy and ingrained in myself to compare foreign, rural mountain village experience to my normalized ‘first world’ experience at home. However, the comparative thought process is biased and does not allow for holistic understanding of a culture. To dissect a foreign culture into component parts and compare each to the realities back at home negates the whole reality these people live in. Oftentimes I would do this unconsciously and feel how certain aspects of rural mountain Indian village life was worse than life at home, thus eliciting a pathos response. Conversely, certain aspects of this life were better than home, thus eliciting idealistic rapture. The fact is, rural Indian mountain life is a wholly different experience than my life at home. Understanding it defies mechanistic, reductionist comparison. Thus to gain an honest appreciation and understanding I had to struggle to identify and curb my nature to compare everything to life at home and seek to integrate my experience abroad within the context of life in a foreign context.

My experience doing research in the Himalayas was an exciting, challenging and humbling ordeal. Conscientious and successful development work requires a constant critique of self, of reasons for doing the work, of internalized assumptions and thought processes. I have never been an advocate of the “I need to travel to find myself” mentality. Everything about you is right inside you, here and now. I do believe, however, that I can find, or learn more about myself by travelling to a foreign place so that I could live differently and subsequently learn and see new things about myself. This experience has reinforced that belief. In presenting an analogy, at the risk of over using mountain travel quotes, a wise person once said, “It is not the mountains ahead that wear you down, but the grain of sand in your shoe.” Thus, the challenge of developmental research work is to find, expose and discard those unconscious mentalities, the grain of sand, that prevent understanding of a culture. Ultimately, it is through this understanding that any effective benefit can be reaped.

Immunization Module - Summary Report

Introduction:

In the 2000-2001a group of McMaster students, member os SIHI, helped Dr. Karen Trollope and Dr. Pradeep Kumar research and develop a health care manual for the Garwhali region in Northern India. By the end of the school year a select company of students were chosen to travel to that region for the purpose of primary research for the health care manual. Students were divided into different reearch groups, focusing on specific topics, one being immunizations. However, before departing the focus of the project changed from the implementation of a manual to an information gathering, primary research direction. In other words, instead of entering the villages a fully prepared and detailed manual, the students entered with the intnet on learning and with the knowledge gained a health care manual would be developed.

The immunization group, consisting of Jonathan Chang and Vikas Bhagirath, left Canada with the preconceived notions that:

and 3) there would be poort access and availability of immunizations for villagers.

We expected to find villagers were completely innocent of immunizations. By coming to India we expected to learn how to properly educate and disseminate knowledge on immunizations through learning the cultural impediments that may resists this helpful practice.

The Five Immunizations (BCG, DPT, Measles, Tetanus, Polio):

All vaccinations are administered while the patient is healthy. B.C.G. is administered at birth or any time after in the right shoulder. This single injection immunizes the child against ??. The child’s arm will be sore for 4 weeks, following the injection and they will develop a permanent scar. D.P.T. is administered to confer resistance to diphtheria, whooping cough (pertussis) and tetanus at three months of age. Three injections with at least one month between the injections are required for the vaccine to be effective. Diphtheria is a bacterial infection which is spread through coughing, sneezing and talking. The symptoms of the disease usually resembles at first a cold or fever. The patient feels weak, has a fast pulse and has a yellow-gray membrane in the tonsils, and throat. Other symptoms include headaches, sore throat and a swollen neck.

Whooping Cough is a respiratory tract infection spread by coughing or sneezing. The disease has cold-like symptoms as well as a low fever. For the first one or two weeks, the patient has a runny nose, cough, redness, tearing and sneezing. After the two weeks the ‘whoop’ cough initiates. The patient develops rapid coughing fits and coughs up sticky mucus. The patient’s nails may turn blue due to a lack of air and they may vomit during their coughing fits. Whooping cough can last nearly three months, however it usually becomes less severe after four weeks. The disorder while not usually fatal for adults can be very dangerous to infants.

Tetanus is a germ found in soil and feces. The germ usually enters the body through a deep wound which is not properly sanitized. After tetanus enters the body the wound becomes infected. The patient will display discomfort and difficulty swallowing, develop a stiffening of the jaw, neck and other parts eventually leading to functional paralysis. The patient may also develop painful confulsions and spasms which can lead to death.

Tuberculosis is a contagious disease which usually develops in weak, poorly nourished children around 15 years of age. TB patients develop a cough with or without sapsms that last for more than three weeks. They develop a feber which lasts for more than two weeks. Patients complain of chest pain and can cough up blood. There is usually a loss of weight, increased weakness and loss of appetite associated with the disease. In the latter stages of TB the patient displays severe headaches, vomiting fits, pale waxy skin, gradual weight loss, loss of consciousness and eventually death.

Polio is a viral infection seen in children under 2 years of age. The disease is spread from fecal matter to the mouth. The polio patient develops a cold with a fever, vomiting and diarrhea. The muscles also become painful which can lead to eventual functional paralysis.

Measles or Rubella is another viral infection which is dangerous for poorly nourished children. In the preliminary states of measles the patient develops a fever, runny nose, red sore eyes and a dry cough. The patient also usually displays a loss of appetite, vomiting and diarrhea. In the first three to four days tiny white spots become visible inside the cheek. After 6-7 days small red spots become visible over the patients’s body. The patient’s immune system becomes weakened so bacterial pneumonia may be observed.

Procedure:

This report will focus on the period between May 12th-May 29th where primary research was conducted in 6 villages surrounding Chirbatiya, where the NGO Jan Vikas Sansthan operates. Between May 2-May 12th, we did, however, visit the UPVHA’s (Uttar Pradesh Volunteer Health Associations) library where we obtained information from existing health care manuals, primarily from Where there’s no Doctor Manual. This is an informative manual, providing information on immunizations for the diseases we were concerned with, however, it was not specific to the Garwhali region, where our manual will be implemented. During the 20 days spent in Chirbatiya we visited 6 villages and the PHC (primary health care centre).

This is the relative location of each villages in relations to JVS (Chirbatyia), each village located either along the road or within 1 km of the road.

At villages 1-3 and 5-6, interviews were conducted with the villagers about immunizations. For the first and last village, the SIHI group was divided according to gender, the females interviewed the village women, the males the local men. Usually more village women showed up to each discussion, varying in age, while the men were fewer in number, and more respectable members of the village (ie. Village elders, the village Don). In the rest of the villages (2,3,5) villagers were interviewed with both males and females present.

The number of people present at each interview consisted of 10-20 people, however, 3 people were typically the prime respondents to our questions. Interviews for our group were conducted through a translator (in Hindi) and sometimes with 2 translators (from Garwhali to Hindi, then Hindi to English). Interviews generally lasted between 5-15 minutes per research group, depending on the amount of time the villagers could spare and the amount of time other research groups spent interviewing.

- Are their Education Days about immunizations at the village? If so, who conducts them?

- How often are your children immunized? At what age are your children immunized?

The only JVS worker we interviewed was ‘Didi’ who is the Secretary (VP) of the JVS. In a 20-30 minute personal interview, with one translartor and a memberof the Immunization group, Didi was asked:

- What did people think of immunizations before the educational programs? Was there resistance?

- Were any of these prevalent in the region before the immunization programs started?

- Are there any diseases that have vaccinations but which people are not vaccinated against (ie. Because of cost)?

Before the immunization program began in earnest in the region were cultural conceptions surrounding the diseases. During the collections of the data it was difficult to get too much information on the subject as the villagers were reluctant to reveal their previous beliefs and instead insisted on talking about their current ideas about immunizations. Prior to immunizations these diseases were prevalent in the region. Sickness was usually associated with ‘devtas’s’. Devta’s are local goddesses who are believed to enter the body of the patient and make them sick for sins committed by the patient, family or village.

The educational programs have been effective and all the villagers we met accept the idea of immunizations. However, when the pgroam first started there was some inistial resistance to the idea. Some immunization can have side effects where the child will appear to be ill with a fever for a few days following the injection. Some villagers were not comfortabe with the idea that injections cause sickness. Now the villagers seem to fully accept and believe int he effectiveness of immunizations.

Immunizations begain in the area 25 years ago. The PHC had the vaccinations but the doctors and villagers did not have the urge to administer them. Even then the immunizations were free of cost. Fifteen years ago there was a nation wide move for immuniztions though “Immunization Days” at schools. These immunization days were effective primarliy in more educated villages and bigger cities. JVS began to focus on health issues and immunizations 18 years ago.

Process of Administering Immunizations:

As a result of the location of the villages and the limited resources of the villages the process of receiving immunizations appears complicated and inefficient. However, all in all, the process seems to be working with most children being immunized. Children can be immunized by three different ways: through AMNs who are travelling midwives that visit the village ona monthly basis from the PHC; visiting a PHC or hospital which can sometimes be quite far and expensive; or through immunization days at the child’s school.

The AMN’s collect the immunizations from the PHC and keep it in a cooler which ensures the vaccines viability for at most 24 hours. The AMN’s then travel to the village to educate people about health issues and administer immunizations free of charge to any children requiring shots. However, people seem to prefer to go to the PHC itself to get shots as the AMN’s system can be ineffective. Sometimes the AMN’s are not able to maintain proper temperatures for the vaccinations and they become defective. Sometimes AMN’s do not visit the villages when they are suppose to because of sick days of unexplained absences.

For every 3000 people there is a primary health centre (PHC) to accomodate basic health needs. The PHC visited by us was a small but clean concrete building consisting of a doctor, a pharmacist as well as AMNs.

The vaccines are stored in refrigerators inside the PHC. The PHC has a back-up generator to ensure that the vaccines remain effective even if the power goes out. The bacterial vaccines (DPT and BCG) are stored at temperatures ranging from 1-8 degrees Celsius. A deep freezer is used for the viral vaccines, measles and polio, which keep the temperature at -18 to -20 degrees Celsius. The vials containing the vaccines have quality control labels on them which change colour to indicate if the temperature was raise too much. The PHC visited by us immunizes children on Wednesdayus and Saturdays. They immunize 20-25 children per week. Sometimes shortages of vaccines are observed. When this occurs the pharmacist places an order with the chief medical officer (CMO) who has the supplies delivered.

Immunization days are part of an effort by the Indian government to ensure that ll its citizens are immunized. During these dyas an AMN goes to a school pre-arranged and immunizes any children who require immunizations. An ink mark is usually placed on a child’s finger to indicate if the child has received a shot. Of the villagers visited all parents seem to be graeful to the progress and were eager to get theri child immunized. Another benefit of Immunization days in that the cost of transporation to the PHC which can be up to 20 kms away around 60 rupees can be avoided. 60 Rs can be adays wage in some villages (Badiyar Goa). In some rural villages parents still hide their children during Immunization days but this is a rare phenomenon.

Our visit to the villages in the Garwhal region while being informative also had some inherent limitations. With only approximately 20 days in the field time constraints prevented us from visiting enough villages to get an accurate representation of immunization issues in the area. Another huge barrier was communication. Although several member so the group were fairly fluent in Hindi, none of them could speak Gharwali so transloatros had to be used. Some specific helath questions ahd to be generalized to accomodate the translators. The size of the group members was too large to anyone to have addequate time to get enough questions across. The villages were observed in the summer months. No inofmration could be gathered about the winter or monsoon seasons. To get informative data more health care professionals should have been interviewed. Another progbem which occurred during the interviews was the cultural barrier between us and the villagers. Many villagers wanted to appear to be educated and informed as they would give answers which would best portray that image. The villagers might have been over generalizing when they said that all children get immunized. Some diseases such as measles and diptheria still occur in the region implying that not all children are being immunized.

Problems:

For the most part, the villagers we interviewed, appeared knoweldgeable and receptive to immunizations. According to Didi’s rough estimate, approximately 60% of children are immunized in the region in which JVS functions. Even though this sections focuses on the problems villagers face with immunizations, such as resistance to or the administration of, the villagers we communiczted with are less critical of the immunization program, because, in the owrds of Saji Kumar (one of our supervisors), “it could be better, but it’s better than nothing.” Furthermore, the educational programs have been in the region for around the past 10 years. People are being educated. Change is slow but coming.

1) Fear of Side Effects - One of the principle causes for resistance to immunizations is the fear of the side effects from immunizations, such as fever. However, according to Didi, this becomews less of a concern after the educational programs are initiated. This could be still an issue in more isolated regions or among people less educated on the benefits of vaccinations.

2) Administrative - The distribution and organization of health care workers in the Garwhali region is a problem. Where 3 health care workers are needed, for instance, only one may be employed, who may, in addition, be an unreliable source of aid. One inconsistency we noticed was the access to immunizations. We were told from Didi and the PHC that AMNs are supposed to go to billages once a month to adminster vaccinations. However, in the first village there was no mentions of this, aside from the facat that they travel to a midwife centre. But villages that rely on AMNs travelling to villages were quoted as saying the following:

This infrequency of visits means that children can not be immunized at the recommended intervals, for instance for the 3 injections for DPT, the child is to be immunized at the 3rd, 4th and 5th month of age. For villages 2,5 and 6, this is not possible. Either the child misses these vaccines or the child must be taken to the nearest midwife centre of PHC which is an expensive trip.

Another administrative problem we noticed was petty corruption. In only the first village we learned that a fee was required for the syringes, whereas the PHC and other villages said no fee was required. For some reason, this village was singled out.

3) Transportation - For villagers that have to travel to the PHC by bus, the fee is around 10-15 Rs per person. Village 6 told us that sometimes they do not have money to take a child to the hospital for sickness or injury. This may also be the case if a child is to be taken to a PHC for immunization. In this scenario, it appears that the villagers would most likely wait for the AMN to come to the village, rather than spend 2/7 of their daily income on a bus ride to the PHC. Children, therefore, will be more likely to receive immunizations at irregular intervals.

4) Storage of Vaccine - The PHC we visited was well equipped to store immunizations. Thre were two freezers with back-up gerneators and ice packs in case of power failure. One deep freezer for viral vaccines was kept at a temperature between -18- -20 degrees Celsius (measles and polio). The other ice-lined freezer was kept at a temperature between 1-8 degrees Celsius. It contained TT, DPT and BCG. The AMNs, however, when travelling to villages carry coolder which keep the vaccinations good for up to 24 hours. We learned from Didi that sometimes AMNs visit villages with the same supplies in a period of 10 days. The immunizations may expire in this period, resulting in illness. It is unkown to us how AMNs maintian the temperature of the cooler for periods over a day and whether AMN centres have freezers like the PHC. Due to the possibility of expired vaccinations, the PHC informed us that, at times villagers do not trust the AMNs. The villagers we met, however, did not show this concern, but were happy with the AMNs.

5) Work Day - One other factor influcencing the administration of vaccines is the work day of the parents and children whcih can conflict with the prescribed Immunization days. For instance, the mother may be in the fields or forest collecting wood when the AMN arrives in the village, missing the proposed immunization days for their child/infant.

6) Traditional Beliefs - In some families, one member or members may resist immunizations. Didi suggests that this person may be and older and more respected member of the household, such as the grandmother. The grandmother may say, for example, “there’s no need for immunizations. My children never got them and they’re okay...” Some people in the community may not recognize the need for immunizations inspite of the educational programs. One interesting point discussed by Didi is the idea that parents that participate in immunization information days are parents that already show concern for the well-being of their children, other parents that don’t go to the information days are more likely not to see the importance or show interest in immunizations.

Treatment for these diseases (TB...) was traditionally treated through davta rituals. The believe in davta’s, a spirit of a deceased villager, is still prominent in these villages and plays a significant part in their culture. In some instances, reliance on allpathic medicince is frowned upon and seen as a negation of the effectiveness of davtas, a denial of a firmly held belief. However, we have seen that villagers are receptive to immunizations once they are informed of the validity of vaccinations.

Future Recommendations:

1) Interview NGO workers first - We didn’t exploit this wealth of knowledge until the day before leaving for the trek. Didi was extremely helpful and provided insights into the billage culture and lifestyle which we could not access in the short time spent there, clues which would take years of experience.

2) Interview and AMN (midwife) and/or Health Care Professional - We only interviewed a Bengali doctor, homeopathic doctor and pharmacist, all who do not administer vaccinations. It would be important to discover how they operate, where they are located, and any resistance (if any) that they might face.

3) Midwife Centres - We only visited a PHC, but it’d be advisable to viist a midwife centre and hospital to see how they operate, the number of centres, how they store the vaccinations and the number of villages they service.

4) Statistics - Research at the UPVHA or at JVS to obtain current statistics on immunizations in the Garwhali region.

5) Seasonal Limitations - We visited the region in May which is spring/summer time. It would be interesting to discover if any of the information we collected changes in the winter months. Is it harder to get immunized in the winter?

6) Remote villages - We visited only villages along the road. These villages have easier access to the PHC, midwife centres and midwives, however, there are villages in more isolated areas where roads do not travel. Are these areas informed about immunizations? Is access to vaccinations more difficult?

7) Dividing the Group - When interviewing the villagers it is highly recommended that each gender interview people of the same sex. We found it easier to get information from people when in smaller group. Furthermore, the village women felt more comfortable conversing openly when only females from our group were present and men from group and the village were absent.

8) Economic conditons - It would be interesting to also understand the economic situations of the villagers, since it plays an important role in their health decisions.

Vaccination	Vaccinates against	Vaccinated at __ years of age	Booster (Y/N)	Other Information
B.C.G.	tuberculosis	at birth of any time after	No	single injection
D.P.T.	Diptheria, Whooping Cough (pertussis), tetanus	-between 3-9 months of age - 3 injections - at least one month of interval between injections	Yes - can be given between 18-24 months of age
Polio	Polio (infantile paralysis)	-between 2-9 months of age - 3 doses (at least) - at monthly intervals - oral vaccine	Yes - 18-24 months of age	-don’t breast feed baby 2 hrs before or after drop
Measles	Measles	- at 9 months of age	No	- protects for life
Tetanus	Tetanus (lockjaw)	- 12+ - 3 injections --> 2 at an interval of one month --> 3rd after 6 months	Yes - every 10 years

Date	Caste	Destination	Distance from JVS	Transportation
May 15-16, 2001	mixed	village 1	5-6 kms	walked
May 18, 2001	-------	PHC	20 kms	bus
May 22, 2001	mixed	village 2	10-13 kms	walked, bus back
May 23, 2001	low	village 3 - Chukrayva	7-10 kms	waked, bus back
May ___, 2001	mixed	4th village - visited school (close to village 1)	3-5 kms	walked
May 26th, 2001	mixed	village 5	13 kms	walked, bus back
May 27th, 2001	-------	Gansali (PHC, hospital, Missionary Hospital, Bengali doctor, Homeopathic doctor)	30 kms	bus
May 28th, 2001	low	village 6 (and Didi Interview - JVS Secretary/Executive VP )	7 kms	walked

Contents

Introduction