Beyond lectures: new ways of learning

All of us who have gone through the institution of formal education know how easy it is to sit through a lecture, look attentive and not absorb anything! Even with a desire to learn, there is a limit to what can be absorbed and retained in the standard lecture format. In recent years, many innovative methods of learning have been experimented with and implemented in schools and non-formal learning centres, among village-level activists etc. During the orientation and mid-term review at CHC Bangalore, we experienced firsthand the benefits of such approaches.

During the 6+ weeks of sessions in June, July and September 2008, we sang, danced, acted, drew, presented and debated. For me, these interactive sessions often crystallized the content of lectures into valuable insights. One game, in particular, challenged our perceptions of the world we live in and ourselves. This was the monsoon game, led by Ravi Narayan, which we played on the 3^rd day of our orientation. It is a role-play which simulates life in a village. Most participants were divided into 8 upper caste, OBC and Dalit families with varying amounts of land. The huge landholders were all upper or the dominant caste, as is common, while the Dalits were marginal landholders. Other participants were moneylenders, government officials, journalists etc.

The game took us through 7 years of planning what to 'plant' and then 'reaping the harvest' in a good, average or bad monsoon. Those who did not have enough to eat 'starved' and a family that went through 3 years of starvation 'died'. While all this was going on, the moneylender was lending money at exorbitant rates; government officials were announcing relief schemes, very few of which the most needy were eligible for and the journalist was documenting the abuses. Finally, at the end of the game, 3 families were dead and the moneylender had acquired a lot of land!

In the post-game discussion, we realized how easily each of us had fallen into our roles, becoming complacent and often selfish as an upper-caste family and feeling powerless as a Dalit family. We appreciated the difficulty of mobilizing communities that are living a hand-to-mouth existance. We also realized that we had forgotten the activist part of our psyche! We hadn't protested, refused to obey the rules or 'organized'. The game was a powerful tool to make us appreciate the lives of the rural poor.

Dwiji and I traveled through the US in September-October visiting chapters of the Association for India's Development (AID), an organization both of us have volunteered with. While planning sessions on topics as varied as Sustainable Agriculture and Group Dynamics, the games and other activities at CHC provided plenty of inspiration and ideas. We wanted to have more discussions and debates and found that these methods were very effective in getting inputs from participants in these sessions.

While we did not have the time to play something as elaborate as the monsoon game, we tried to come up with a shorter role-play to illustrate group dynamics in the presence of an 'outsider'. The role-play is quite simple – most participants are villagers, while two are the 'change agents', representatives of an NGO. Each person is given a chit that assigns them their role and provides further information that they can choose to share or not share. The background is that the change agents are at the final stage of selecting the village as the site for a new high school which their NGO will manage, but they feel there is something the village is not sharing with them that could impact the success of the project. Their goal is to find out what this 'secret' is. On the other hand, the villagers are vested in seeing the school set up in their village and the resulting benefits. At the beginning, both the change agents and the villagers are allowed time by themselves to strategize – then comes the interaction between the two groups.

We played this game with the volunteers of two chapters and found it was even more successful in illustrating group dynamics and negotiations between groups than we had expected. Hierarchies were formed within the village group and the change agents in both chapters took different approaches – confrontational and friendly - while engaging with the village. We analyzed these interactions later and discussed their pros and cons, comparing them to modes of engagement in the field. Further, a number of issues were raised that were not covered in our initial briefing but are, in reality, important for a school's success. We discussed child and adult education, child labour, migration to cities, public land in a village, mid-day meal schemes and more.

Whether these interactive approaches are more effective than traditional methods remains to be seen. I think they are and we certainly enjoyed planning and participating in them! I hope to benefit from more such games and interactive sessions in the future, whether as just a participant or a co-ordinator and planner as well. In such an interactive process, we all learn and what could be better than that!

At the mercy of Mother Nature

August 2008

Growing up in Bombay, I thought I understood the downsides of monsoon well – the unceasing rain, the flooding, bus and train delays and cancellations... I prided myself on not just coping but also enjoying the season. Of course, things were much worse for the slum dwellers and people living in low-lying areas. But the rains would eventually stop and things would get back to normal, right? It took spending a few weeks in Sitapur in July-August to really appreciate the short-term and long-term impacts of the monsoon.

Most of the SKMS members are agricultural labourers or marginal landholders. They live in 'kuchha' mud houses with thatched roofs. This year, the monsoon was so fierce that it was, in the words of an SKMS supporter, 'Nature's terror'. All the fields were flooded through July and only the paddy seemed to be surviving. But further downpour through August and during the critical period of harvest damaged the paddy crop as well.

In the second week of August, it poured nonstop for 3 days. Houses, already unstable with the water-logging, began collapsing by the dozen – in some cases just one wall, in others the entire structure. These humble homes provided very basic shelter; with their collapse, people were all the more vulnerable to the elements. In one village, entire families spent days under plastic sheets hoisted next to a statue of Ambedkar, the one area in their 'basti' that was not waterlogged. Fevers, diarrhea etc. were rampant. The spring's wheat crop had been a bumper one and many families had stocked up on grain for the entire year. This grain was now wet, spoiled and mostly unusable.

While all this was playing out, we were hearing of the calamity in Bihar where the Kosi changed track and inundated entire districts. The suffering of the people in the affected districts was unprecedented. Even in Sitapur dt., certain blocks such as Rewsa were completely flooded and people were camped out on the roads and highways. Was the suffering of those people worse than that of the people here? After a point, can one quantify suffering?

We were ourselves staying in Surbala's house in the village of Satnapur. Surbala, through sheer determination and some financial strength, had constructed a concrete 2-room house. Unless there was severe waterlogging, her house was safe. But her husband was sick, one of the walls in her in-laws' house had collapsed and she was busy with personal and SKMS work. We were in a quandary – should we leave 10 days from now as we had planned or leave earlier? If we stayed, should we move to a hotel in Sitapur? Our utility to the sangathan was limited – we could help out with the applications for compensation for all those who had lost homes and property, but there were more experienced people already doing that. We could not work on long-term projects in this emergency situation. So we decided to leave early. It did not feel good to leave at such a time...

The rains have now stopped in Sitapur. It is likely that the damage to families' food stocks will have an effect in the coming months, though work through NREGA can mitigate that. It is to be seen how the winter will be. We will be back in Sitapur then and will hopefully contribute in a better manner than we could in the midst of the monsoon fury.

Becoming a 'jhola chhaap' doctor

'Jhola chhaap' is a colloquial term used to describe informal medical practitioners in some parts of India. These are usually people with some experience with medicines and health care – they may have worked as a compounder with a doctor somewhere or received some formal/informal training or just picked up medical knowledge along the way. But health services are so scanty in rural areas that these people can get elevated to doctor-like status. At CHC, we've had a few discussions about such practitioners – are they just quacks who should be discredited and banned? Or are they providing a valuable resource in the absence of trained professionals? Some groups have been working with such practitioners to improve their techniques – a powerful example is the trainings provided to traditional dais (midwives) to promote safe deliveries, prenatal and antenatal care etc.

The ease at which one can become a medical authority was brought home to me in Sitapur district this August. Malaria seems to be quite prevalent here – exact numbers are hard to come by. In Mishrikh block, only the town of Mishrikh has government and private labs that can test for malaria. The time and expense (including travel expenses and loss of daily wages) involved in the testing process discourage many people from going through with it. We were discussing this issue in the Sangtin Kisaan Mazdoor Sangathan's (SKMS) regional meeting at Qutubnagar and I asked what people did instead. One or two replied that they go to a 'doctor' in Qutubnagar who injects them with some medicine that makes them better.

Many situations have come up in Sitapur where people have taken decisions or acted in ways that I am sure are wrong for them. But I have often kept quiet due to the lack of alternative options for them and because I did not want to get into an indefinite 'lecturing' mode. Even with friends and family in one's socioeconomic strata, we choose to keep quiet during difficult discussions to keep the peace. But here, I decided to speak up and told the group that that was not the right way to treat malaria.

'Then what is the right way, didi?' asked someone. I mentioned chloroquine, the most commonly used drug for treatment or prevention of malaria. The group talked among themselves and more people joined the conversation. A little while later, another SKMS member came up to me and confirmed the name of the drug. By that evening, a number of people had bought chloroquine tablets to stock at home and had told their fellow villagers to come to them if they had 'jaada bukhaar' (cold and fever, the colloquial term for malaria)!

Was this the right thing to do? What if they used the wrong dosage? What if....? I was quite worried at this outcome and wondered if I should have instead pushed these folks to get tested and get proper medical advice from trained professionals. I called Sukanya at CHC Bangalore and the feedback she gave provided some comfort. She suggested that I talk to doctors in the area and the PHC and government staff to get an idea of the malaria situation in the area. Also, CHC would send me pamphlets on malaria, its diagnosis and treatment (written in Hindi) that I could distribute to the group and use for further discussions. 'You gave them the right information,' she added. 'The need for good health services in these communities is so acute that any good information they get can only be beneficial. So don't hesitate to share complete and accurate information – we all have a role to play.'

So this is how, for a short time, I became a 'jhola chhaap' doctor! I expect to fulfill that role again in the future and hope that I will be able to respond in a sensitive and useful manner. After all, when campaigning for 'Our health in our hands' (a message of the People's Health Movement), each of us have to step up to the challenge as best as we can.

In search of a doctor (and the system)

Again, it's been a long time since I posted - apologies! Also, considering the record length of my posts, I'll try to post shorter, more reflective pieces from now on!

August 2008

The orientation at CHC had given us a thorough introduction to Community Health. But in Sitapur, given that Sangtin Kisaan Mazdoor Sangathan's (SKMS) primary work was in mobilizing for NREGA, I did not plan on sharing my learnings at their meetings. My plan was to discuss these issues with a few people and then see what came through. However Mukesh, who serves in an advisory role with SKMS, suggested that I speak about health at the regional meetings using one or two talking points, thus starting the thought process in this important topic. Other SKMS members concurred, so I raised the issue at the Aug 10th and 11th meetings in Aant and Qutubnagar respectively. We discussed why it is easier, or rather more natural, to work on livelihoods, BPL etc. than on health – we only think about the health system when we are sick, knowledge and power are concentrated in the hands of medical professionals etc.


I asked the assembled people, about 100-150 in each meeting, to think about health-related issues and come up with one or two that they would want to work on. While everyone was mulling over this, a few people raised the issue of malaria. At this, others began speaking up about their own and their village's situation. From there, matters progressed very quickly, and before I knew it, plans were being made to prepare lists of people affected by malaria and to demand action at the block level.


I was not sure what to do with the information being collected, so contacted CHC. Armed with their advice, I went to meet Richa. She was quite concerned with the various illnesses prevalent in SKMS villages this monsoon. She felt that camps should be organized in a few central villages so that all the sick could easily access health services. We decided that I would meet the chief doctor in Mishrikh where a CHC (Community Health Centre) is based.


But first, a brief description of the area: the Mishrikh CHC serves most of Mishrikh block, with some villages as far as 20 km away. The average cost of travel one-way is Rs. 10. If the patient needs to be escorted, travel costs themselves could be as high as Rs. 40. Further, patients need to get to the CHC before noon to get a 'parcha' or token that would allow them to see the doctor, get medicines etc. Transportation in the form of tempos is not very reliable and if one is late, the entire day is wasted. In contrast, Qutubnagar, one of the big villages, is more accessible for the people in that area and has one MBBS doctor who charges ~Rs. 40 / diagnosis and a couple of 'Jhola chhaap' doctors who charge even less. But inspite of this, the Mishrikh CHC is well used as I discovered when I visited it on August 19th.


The chief doctor was not available – he was on leave till the 28th, the day after we were scheduled to leave Sitapur. Further, the situation was dire in many villages – just that morning, we had heard that the entire Dalit 'basti' in Kunwarapur was inundated with both lake and canal water. There and elsewhere, many houses had collapsed and people were exposed to the rains with nothing to protect them but plastic sheets. While I was in Mishrikh, Dwiji had gone to Kunwarapur and was wading through knee-deep water helping to document the damage.


On further enquiry, I found the junior-most doctor on service. He was swamped with patients. While watching him interrogate each patient briefly and jot down a prescription, I was reminded of Adithya recounting his health camp experiences at CHC Bangalore. In such a situation, the doctor can spend at most half a minute on diagnosis. It has got to be dehumanizing to treat patients as if they were parts on an assembly line. I managed to speak briefly to the doctor and ask him what planning the Health department did for malaria and other diseases in the monsoon. He looked at me like I was delirious – 'We are here treating patients – that's what we do!' I then asked what would warrant a personal visit by a team of doctors to a village. 'A serious outbreak of diarrhea or something equally contagious and life-threatening' was his reply before he was engulfed by patients again.


Given the lack of progress at Mishrikh, I went to the District Hospital in Sitapur the next day hoping to get more answers. Here, I was luckier – the additional CMO (Chief Medical Officer) and the Deputy CMO were both in the office and the latter was in a chatty mood. He talked about the staffing problems in the district – there was a shortage of at least 30 doctors. Government service and a rural lifestyle cannot compete with the salaries and career growth possible in urban settings. Currently, even C-sections had to performed in the District Hospital as there was no anesthesiologist at the CHC. They were under-equipped for normal times, let alone catastrophic situations. He then went off on a slight rant about how ignorant and lazy villagers were and how hard it was to treat them. These were comments similar to what I heard the past couple of days from private doctors in Qutubnagar – the path of least resistance in this thankless situation seems to be blaming the victims.


When pushed on health camps, the Deputy CMO said that a team would visit a village only in exceptional circumstances. Usually, there was a good reporting structure in place and news of outbreaks almost always reached them. In fact, in some situations, they had gone to villages and found that the situation there was not as dire as expected. Such visits were detrimental since the team could have spend their time better in the hospital treating the patients who arrived there.


After this discussion, I came to the conclusion that it would be very hard to get a medical team to visit any of the SKMS villages. Other areas in the district were in worse shape – in some blocks, villagers were practically living on the roads as all other areas were flooded. Nevertheless, I communicated this information to the SKMS team and they did try to get a team to visit Kunwarapur.


Two days later, we went to visit Reena and Shammu at Kunwarapur. No medical team had come to assess the situation. But we learnt that, in a nearby village, 7 children had died from diarrheal-related causes the previous day. So much for a good reporting structure...


But given the dire state of the Health system and the realities of rural life here in Sitapur and elsewhere, many such tragedies are in the making...