02.04.2010

Kinnari Jhaveri: Public Health for Migrants

Progress Reports

Mid-Year Public Progress Report

Salumber, Rajasthan

Kinnari Jhaveri, a graduate of University of California, Berkeley is partnered with Aajeevika Bureau. Driven by her passion for preventative health, along with her love for India’s strength of community, she has been focusing on the implementation of a preventive health program based on education, group support and behavior change. Most recently, her team held a one-day health camp for women and children’s health issues treating over 120 patients from two panchayats.

Ajeevika Bureau Background

Walk to a tea stand in the city of Ahmedabad, Gujarat, or through a construction site, restaurant, or factory, and ask the working men where they’re from. Chances are they’ll tell you they’re from rural Rajasthan, traveling to the chaotic metropolis far away from their fields and families to earn a living.

Millions of migrating men and women form the backbone of several large cities in India, working in the vast labor sector of these urban centers. Despite the magnitude of their contribution to India’s informal economy, migrants are a largely invisible and exploited population and remain the poorest of the poor. Entering an unfamiliar city with no established identity or livelihood security, migrants experience hazardous working and living conditions, lack of basic access to healthcare, and frequent workplace malpractice.

Born from a vision to transform migration into a more positive opportunity, the Aajeevika Bureau was founded in southern Rajasthan, a major source region of migration. In five short years, through innovative services such as migrant identification cards, legal aid and education, and life skills counseling, Aajeevika staff have transformed the lives of thousands of migrants by helping them establish their identity and build self-confidence, improve their work security, and upgrade their skills in the aspiration for a dignified working life.

Community

Given that male migrants travel to their workplace destinations for several months at a time, the families of migrants suffer from their prolonged absence from the village. Wives and mothers, as well as young children, take up larger workloads in their homes and fields. Social constraints and lack of knowledge often prevent women from accessing basic local services such as reliable healthcare. Moreover, the emotional stress of separation is an added burden for the entire family, one that is difficult to comprehend but manifests itself in several ways.

An Indicorps Fellow and migrant myself, I live in the tehsil of Salumbar in southern Rajasthan, and the wives, children and parents of migrants form my community. Within the town of Salumbar, I live with Divya and Rekhaji, fellow Aajeevika team members who are nothing less than family. Eating and sleeping together, sharing tons of funny stories and our share of tears, and being unafraid to disagree with each other has made our little family very real, honest and strong.

Over the past six months, I have also grown to know and love several women and their families in five panchayats, whose growing affection towards me have made this experience a very personal one. Although I am miles away from my last home, in a place where at first I barely understood the local dialect and visually stuck out like a sore thumb, the unconditional warmth and openness of the community offered the emotional space for me to completely be myself in the remotest of villages. Concurrently, Rekhaji and I have become close confidants for many women, who share their deepest personal concerns and seek our help for their worries.

The August 2009 Fellowship marks the first class to based on a team model. This model gave me Rikin Tank and Simmi Dixit, who truly are a brother and sister to me. The three of us are based in different centers but actively share our feelings, ideas and thought processes, creating a balance where we productively support each other while enjoying the space to individually lead our projects. I cannot imagine this year and beyond without their presence in my life.

Project Vision

The Bureau operates both at the source villages of migrants as well as the destination cities, and focuses on strengthening the source and destination links of its services to better assist migrants on both ends. Given the increased efficacy of the two-way model, this year marks the beginning of a pilot health program that will be implemented at the destination center of Ahmedabad city with male migrants as well as the source block of Salumbar with their families.

Within a broader vision to create support services for migrants’ families, my project involves building a preventative health program for my community in Salumbar that can later be adopted by the various source centers of Aajeevika. Our health model focuses on nutrition and hygiene through the implementation of health education and linkage to existing government health services. Following a community-based structure, we will select and train female leaders from each of our target villages in basic health education, while concurrently forming ujala samoohs, groups where wives and mothers of migrants can meet, gain education and access to several services from the trained leaders, and transform into communally supportive and self-empowerment units through concrete program ownership opportunities.

While piloting a new developmental initiative, it is often tempting to design as impressive a model as possible that addresses the more complicated challenges faced by the community. At times, the most basic and highly prevalent issues are ignored simply because they have existed for a long time and are known to everyone. I am particularly proud, therefore, that our health model is basic and preventative. Lack of adequate nutrition, coupled with poor hygiene especially related to drinking water, easily constitutes a majority of the common health issues faced by villagers in the region, if not the state. A health program focusing on, say, AIDS and sexual health would indeed be beneficial in its own right, but addressing the most basic health needs that exacerbate the malnutrition – low immunity – high infection cycle before a more advanced intervention is, in my opinion, a crucial, often unrecognized necessity.

Furthermore, the implementation of the program is based mainly on education, group support and subsequent behavior change. I view behavior change as the very essence of preventative health and arguably the most difficult change to bring about. I am convinced that the majority of the world’s illnesses, ranging from obesity in the United States to tuberculosis in India, can be reduced greatly with preventative health practices. Yet, my relationship with preventative health is a love-hate one, because it is a concept that is difficult to teach and one that doesn’t stick easily in people’s minds. Everybody is too busy solving all the problems in front of them to worry about preventing problems that haven’t yet occurred.

Creatively coupling our efforts in health behavior change, therefore, with support services whose benefits are more easily identifiable by the community, will potentially help the intervention “stick” with the families. Our health program not only focuses on health, but includes peer-to-peer accounts training, establishing bank accounts, signing up for life insurance, joining pension programs, and more. I also hope that our groups will conduct small-scale income-generating activities based on health principles, such as hand-making and selling fly domes for open food and sleeping infants, and cooking nutritious meals at nominal prices for the village at large during religious events.

Project Implementation

Progress

My initial time in Salumbar involved conducting a small informal study on health-related problems and behaviors of the families of migrants, after which we finalized the preventative health focus of our program. With the study began the ongoing process of building relationships with the women of five target panchayats, as well as my personal education in the realm of fieldwork. I experienced firsthand the difference between having a prior entry point in the community and creating one myself. The need to create my own entry point with busy women who have never heard of my NGO taught me how to gain their trust on my own and be respectful and gentle in my approach given the sensitive nature of my questions.

Following the study, we continued general outreach and rapport building that led to holding a few panchayat-level women’s meetings, in which women were provided with information about our NGO and its core services, and through participatory discussion were encouraged to be a part of our new women’s health program. A larger health meeting at the Aajeevika office in Salumbar, attended by women of four panchayats, served as the first landmark event of the program. Practical demonstrations and illiteracy-friendly posters accompanied basic nutrition and hygiene education, and the “problem” of such health issues was personalized for the women, facilitating their recognition that the issues under discussion were directly relevant and applicable to their own families. Women were taught some basic solutions to common health issues, with the aim to demonstrate the benefit of joining our health program. They were further motivated to participate in the local village groups the Bureau would help form, and those who were interested were invited to join as health leaders of the program.

Most recently, our Salumbar team held a one-day health camp for women and children’s health issues, where a general practitioner from the local primary health center and a private gynecologist treated 120 patients from two panchayats. Collaborating with the community health center in Salumbar offered me a realistic experience of the diligence it takes to move things forward with a government department and the preparation required in case plans and promises fall through. The camp also provided the perfect chance to demonstrate to several people the use of a Tippy Tap (a hands-free, water-conserving hand-washing stand made from tree branches, some rope and a 5-liter container). Given the focus on hygiene in our program, I am determined to promote Tippy Taps as actively as possible through our women’s groups as well.

Community and Staff Role

As an Indicorps fellow, I perceive my role in my NGO to be one of a facilitator. The point of my presence is to eventually bring the project to a stage where its success does not depend on my presence, and is primarily community and team-based. In that light, I try my best to share my knowledge and thinking processes with members of my team, and in turn learn from their expertise.

In addition to centering the program around village-level women’s groups and peer education, our health events involve outreach using the local health personnel network such as ASHAs (para-health workers) and anganwadi workers, as well as friends and potential health leaders in the villages. The active involvement of the local NGO team, while at first limited to one or two people, has slowly evolved into a true collaboration, in which all members of the Salumbar office played an active role in bringing our latest event, the health camp, to life.

Future Plans

I believe that the past few months’ worth of building meaningful relationships will go a long way in effecting positive change in the community’s health habits. Whether or not the duration of my stay allows me to see the project to completion, I would like to actively apply everything I’ve learned until now in fine-tuning the complete model of the project, after which the Bureau team can adapt as they see fit.

Over the next several months, in addition to holding high-quality educational and participation-based health camps, my goal is to help establish highly active women’s groups that act as self-empowering units as well as channels to my NGO and reliable local health services. In addition to benefiting from concrete Aajeevika services, an ideal samooh would involve women supporting each other on a very personal basis given the absence of their husbands.

Over time, I would like to see the activity of the samooh evolve as follows:

-    Begin with health education in nutrition and hygiene, along with connecting to general Aajeevika services such as life insurance and pension programs. Also, begin a basic savings structure within the group (potentially in collaboration with the RSSA – a financial solutions company affiliated with the Bureau) and include house accounts training.
-    Evolve health leader training so as to encompass dispensing of basic medications and treatment of small injuries. This will go hand-in-hand with counseling women on accessing reliable health services versus unreliable, often doctors. Assist women in determining their family’s average health costs, which will help encourage following good health practices.
-    Move on to collective outreach activities, such as making posters for the villages on important health issues to involve more of the community. One idea is to encourage larger village meetings where samooh members would impart health education through role-play, small skits and body-mapping activities.
-    Once trust has been strongly established among women, consider establishing a baby-sitting program within the samooh, given that the absence of the husband means one less adult to look after the children.
-    Advance the RSSA collaboration in micro-finance as based on the needs of the samooh and the potential growth of RSSA’s own presence in Salumbar. Consider health-related income-generating activities such as hand-making fly domes.
-    Health education evolves to more sensitive matters such as sexual and reproductive health. This will be in tandem with the progress of health education at the destination with women’s husbands, thus addressing sexual health with both the wife and husband.
-    As the strength of the samooh evolves, consider larger-scale village events where the samooh cooks nutritious meals for nominal prices.
-    Funds allowing, encourage women to enroll in Aajeevika-led training programs.

On our end, it is absolutely crucial that we actively communicate with samooh members and offer them a safe space to share their thoughts with the Aajeevika team, so as to determine how effectively the program is improving their health practices. The challenge of a preventative health program is that its behavioral outcomes are not always easy to measure, and so it is imperative to monitor and ensure that women are truly benefiting from our program.

My remaining time will also involve a shift in my team role. Salumbar has been on the rise, and I would like to see it transforming into one of the most active and positive workplaces in my multi-centered NGO.  Under the mentorship of my NGO director, I plan on becoming a more integral member of my team while balancing the demands of the more specialized project I’m working on.

Personal Growth

Having grown up in Bombay for ten years, I have always felt a drive to find my way back to India one way or another. I never imagined, however, that in six short months back home, my personal growth would be greater than I have ever experienced in my life.

The past few years have been ones of struggle and self-doubt, to an extent where at times I could not recognize myself in my state of stripped confidence and creativity. I had become a person who tried too hard to impress others while forgetting to remain true to myself, and had adopted a negatively skewed lens of reality that had transformed me into a pessimist.

Over these past months, friends say I have “changed.” I believe that I have simply returned to my true self. Such a simple statement to make – yet I cannot adequately describe how rewarding it has been for me to regain myself, and I do not take this change lightly.

My new environment has unfolded with no shortage of challenges. From the first few weeks during which I perceived my difficulties as insurmountable – especially ones related to poor team dynamic – I have, over time, developed an unshakeable trust in myself. As someone who tends to get stressed easily, I now live by the simple principle that hard work, dedication and passion always pay off – a conviction that has greatly bolstered my optimism. The guidance provided by my Indicorps mentor and staff has helped me develop very powerful and very real levels of patience, respect and understanding, which although difficult to sustain have never failed to help me alleviate tough situations. I strongly believe that these simple and self-challenging principles have helped advance my project and have triggered several positive changes in my team and myself.

My time in Salumbar has created a ripple that will pervade every nuance of my personal and professional life, and these simple principles, which have only strengthened over time, are worth every last ounce of effort they demand.

Kinnari Jhaveri, August 2009 Indicorps Fellow

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