Sept 15, 2008 – Mar 15, 2009
Tribal Health Workers Training
Gudalur Valley, Nilgiris District, Tamil Nadu
Abirami Natarajan, August 2008Fellow
Background of NGO
Two decades ago ASHWINI was started by a young Indian couple living in the United States – they set up a small hospital, trained local adivasi youth to be community health workers, and carried out extensive health education in the field. Its mission is to provide accessible, acceptable, and effective health care to adivasis (tribals) in Gudalur Valley. It’s philosophy is exceptionally unique in that it empowers members from the community to exercise ownership and decision making over the very institutions that aid their development. ASHWINI works closely with other sister organizations that focus on improving education and economic development forming a quite successful holistic model of development.
As an August 2008 In dicorps fellow, the project set forth was to design a training curriculum, create teaching materials, and work with the senior doctors to help train 8 young girls from the adivasi community. Over the course of the year, the curriculum and materials will be tested, modified, and can be used as a model to train other community health workers entering this health system (either as
nurses in the Gudalur Adivasi Hospital or community health workers in the field). Training adivasis, many of whom have completed only up to 10th or 11th standard empowers these young men and women to truly take ownership over their community’s health. Moreover it draws them into an inspiring community of productive people, many of whom have dedicated their lives towards a purpose greater than themselves. My vision is to both to help train these girls in the basics of community health, but also instill on them the confidence of what they arecapable of, and the space to be free and have fun.
Project Progress and Future Plans
When I first came to Gudalur, I was from day 1 immediately introduced to my project. It was both exciting and overwhelming for me to be in a place where I immediately saw the so much potential for learning. One of my initial concerns was not being burden on my NGO – many of the founders working here heavily invested in my learnings and personal development. Working directly with these people has always been an inspiration to me. I will always be appreciative of their investment in me, as it allowed me to learn a great deal about medicine and
development firsthand from people who have been working at the grassroots for decades.
Eight young, exceptionally bright, and hardworking girls were selected prior to my arrival from local adivasi villages to be trained this year. The training for the new batch of the community health workers had already started, and I was quite eager to be able to contribute. Early on the realization hit me that there was a lot for me to learn in order for me to have the perspective to create a curriculum, teaching materials, and ultimately help with the actual training. So I immersed myself in the hospital, sitting in during outpatient, going on rounds, going on themobile clinic, and villages to get an understanding of what the biggest health problems were and how the community health workers address these problems. As I became closer to the new trainees, I found that they were slightly intimidated by the of the doctors who were teaching the class, and some of them completely did not understand what was going on because they did not know Malayalam at all. I also found that someti mes the classes were being taught way above the level at which these girls could comprehend, which made them feel as though they would never be able to understand what was going on. I felt that explaining the material starting at a more basic level would make them more confident about their abilities and interested to learn more. So I started by going over the material in the evenings one on one with the girls, trying to explain the concepts rather than have them mem orize facts. I also wanted them to be curious about what was happening, and be fearless in questioning and understanding, rather then just seeing their role as doing what they were told. I wanted them to view class as a dreadful event, or study out of fear, but see it as an opportunity for them to exercise their curiosity and creativity. I realized that this was ambitious, but I still believed worth trying. I learned that these girls were just like me – they had left their families and come to a strange place with the desire of learning andand doing something positive for their community. Many of them were homesick, and contemplated quiting. I wanted them to feel at place here, and most of all have fun.
The primary focus of my work in the last 4 months is to delve into the training.This was initially quite time consuming because it was the first time I was learning the material, but being in the hospital and field trying to put all the pieces together was like exploratory detective work. It did not feel like work, but just learning and seeing things that I was interested in. Class times were probably one of my favorite times of the day because I realized how much I liked the challenge of explaining things in a way that people can understand. I also felt like I was contributing in a concrete way. In addition we have been documenting the training in a book that is specific to the health issues and protocols in Gudalur that can be used by the trainer and community health workers in the futures. These materials will also be available on the ASHWINI website so that they can be of use to other organizations in Tamil Nadu training community health workers. I think that the curriculum and training materials should be finalized within the end of April. It will then be completely edited and modified based on the suggestions of the senior doctors here, at which point it will be finalized. Completing this project can be feasibly completed before I leave. In retrospect I could not think of a better project that would allow me to study my interests as well as accomplish something productive, but at the same time I also believe that the work that I have done here could be done by anyone with an interest in medicine and public health, capable of putting in hard work, and enjoys both
learning and likes teaching. While not working on the primary project, I have been happy to help with any other task that needed to be done to help the growth of the organization – even mundane tasks, such as data entry, helping people fill out visa forms, and report writings – either provided me with some learnings about the organizations or an opportunity to become closer with some people I normally would not have encountered. The last 6 months have been a stage of tremendous learning and growth, and I am humbled as I am reminded every day how much I still have to learn.
As I move forward into the last 4 months of my fellowship, I hope to push myself harder to explore the larger issues I am frustrated about and uncertain. This involves really probing about how to go about addressing systemic change that blocks the improvement of health and development. For instance, the health conditions in Gudalur have reached a roadblock in terms of improvements that can be seen solved by curative care. Improvement now requires systemic changes in nutrition, sanitation, housing, and alcohol and tobacco deaddiction.
Many of the issues are beyond the capacities of the NGO, and require governmental change. While I recognize that this type of change may take years or even decades, I want to dig deeper into these questions that people here say is impossible to change.
Because ASHWINI is completely isolated from India’s government health care system, I have not learned as much as I would have liked about this is realm. I think this is important for me to study because it is the major source of health care for people living below the poverty line. Quite coincidentally, just this last month ASHWINI plans on introducing a new Central Government Scheme called National Rural Health Missions Scheme (NHRM) that essentially aims at understanding the level of which rural populations know about these public health services and improving their knowledge, and ultimately access to such services.
Learnings & Personal Growth
One of the reasons I came to India was to live among and understand both social and health inequalities. The truth has sometimes been unpleasant, depressing, and emotionally draining. Spending much time in a rural hospital, it has been difficult for me to be so closely exposed to suffering and death. It has been a constant challenge for me to form meaningful relationships with sick people while internally remaining composed, peaceful, optimistic, and happy – I am still working on this. However, I believe that it is the very experience that move me
that also deepen my conviction to go into medicine.
Some of the health problems that I have studied and seen in India seem so enormous and daunting – so deeply entrenched and impossible to change. How do exploited and marginalized adivasis who were once living in precarious health conditions now live with health indicators significantly better than India’s national average? In some ways I believe that being here is exactly what I needed at this time in my life. The organizations here in Gudalur is a living breathing example of one model of successful change. And it has been a privilege for me to be hereand learn. I have spent a considerable amount of time trying to understand the history of this organization and how exactly change happened. I believe that my most important learning, while it may be simple and obvious, is that change is indeed possible. It is truly inspiring to see how much positive social change can occur when a small group of dedicated people make a concerted effort – moreover, this does not have to occur at great personal sacrifice. In fact, I have found that the people here that are most effective are those that wake up every morning and do what they love doing the most. I strive to follow in their footsteps.
One of the biggest needs I see in India’s rural health care is committed physicians who are abl e to work at the grassroots, systematically research their experiences, and work towards advocacy and impacting policy. For instance, in Gudalur there have been many roadblocks to change that cannot be addressed by nongovernmental insti tutions. TB, diarrhea, and malnutrition can be only impacted a certain amount by health education and curative care – these diseases also require more systemic changes that the government has the potential to provide– such as housing, better nutrition options, and clean water. How does one get the government to cooperate and see the needs of the people? There are
certain government interventions that have been incredibly successful (government immunizations have been very effective) – how do we tap the government’s potential in creating more of these successful changes? This has left me with more questions and confusion than clear cut answers. I realize that I am only scratching the surface and that there is a lot for me to learn.