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Jonathan: Rural India

March 19, 2011

I write this evening from the rooftop of Jatan Sansthan in the village of Railmagra, roughly 70 km outside of Udaipur in southern Rajasthan.  Essentially located within cultivated desert, it has been crawling up past 100F each day (around 40C).  Supposedly it gets hotter, but not by much.  And the best part is that men still wear jeans.

I’ve been having lots of amazing and eye-opening experiences, but more on that later.  First, some background…

Railmagra, with a population of 10,000, is located within the district of Rajsamand (a city about an hour and a half by bus with a population of about 5 lakh [500,000] people).  Railmagra, as a medium sized village, is thus an important locus point for the scores of nearby villages that may comprise of just 100 houses or less.  While there is a small market (about three city blocks in US standards) and a substantial network of winding inner streets, fields are always just a 15-minute saunter away.  Rajsmand District is perhaps best known for being an important departure point of migrant laborers to the majority of central India.  Traveling as far as Mumbai (about a 24 hour train ride), these migrants are overwhelmingly male and have an average age of just 14.  These young people are, in many ways, at the forefront of the new India: connected to the village and to the city they are the laborers that support the booming middle and upper classes, they interact with the globalized economy and bring it back home, and they in turn work to either dismantle or reinforce ‘traditional’ Indian culture as it has always been constructed.

Since the time of Ghandi, and largely because of him, most Indians see the village as the center of Indian life and culture.  This is, of course, greatly complicated by the fact that there is not one India but rather a collection of diverse cultures, languages, peoples, religions, cultural mores, and paradigms that construct a diverse nation.  The village is merely an iteration of India, yet Railmagra provides a fascinating case study as to the ways that migration is changing the lives of Indians in economic, cultural, and health frameworks.  Presupposing that migration is intimately connected to globalization, and that it has important effects for the construction of a more nationalized Indian identity, this has both macro and micro implications for the lives of rural to urban migrants.  Yet all of this is yet to be more fully discovered, and I am busy trying to soak in as much information as possible.

India is currently in the second to last year of a major and much discussed health initiative titled the National Rural Health Mission that seeks to provide adequate access to health education and care for all.  This is accomplished through a number of programs both social and structural in nature.  The most exciting and innovative program is abbreviated to ASHA (meaning ‘hope’ in Hindi) that are a collection of women (1:1000 population) who are responsible for the health and wellbeing of women and children in the community.  Selected based on their community acceptability (i.e. current marriage status, children, having married into the community [since those who are from the village may be married out of it or may make other women uncomfortable]), these women have knowledge in basic first said, ante- and post-natal care, and general welfare.  They primarily, thus, act as front line workers in linking individuals up with the formal health care system in a way that is comfortable, culturally appropriate, and to some degree effective.  This formal structure is further delineated by the Mission, which has set up a number of types of health care settings.  In order of size they are Health Sub-Center (with two basic nurses on staff), Primary Health Center (with some nurses, and perhaps one or two generalist doctors), Community Health Center (CHC; beds and some specialists), and finally district hospitals (many doctors, beds, and capacity for major procedures such as surgery).

As previously mentioned, Railmagra is an important midpoint between the smallest villages and larger cities such as Rajsamand and Udaipur.  As such, it has a CHC that happens to be just a few feet from the office I am currently living at.  After learning so much about the Mission and its works, I was accepted the opportunity to tour the facility with a special emphasis on its maternal health ward.  What I saw was alarming and at times very worrisome.  The language barrier made it difficult to ask questions, and much of this is matter of my interpretation, but the fact remains is that the CHC lacks many of the most basic necessities to provide adequate health care to such a disadvantaged population.  I need not provide a laundry list of worrisome sights I saw, for reality stands that I am not qualified to undertake a hospital evaluation.  I do, however, feel comfortable sharing some of the issues the OB/GYN on staff indicated herself as being major issues.  While she has the technical qualifications to perform cesarean sections she is intermittently able to do so given that the hospital has an unstable supply of blood or medicines.  While the district hospital (just 20 km away, but about an hour and a half by bus) can perform these more complicated procedures, it is deeply worrisome that a woman identified with a difficult birth at a Primary Health Center may travel very far to the Railmagra CHC only to need to be transferred again to the Rajsamand District Hospital.  Depending on the adequacy of the systems functioning, this may take many valuable hours and a significant amount of money for the patient (even if the care itself is technically free).  Further, in a hospital with thirty beds, there is such a severe shortage of nursing aids that some nights there is only one.  Without making any unqualified statements, it is safe to say that medical supplies were in disarray, the hospital was not sterile, and there was not a standardized system of the disposal of bio-waste.  In a country with no sanitation system, it is too unclear where items like hazardous materials and sharps are disposed.  Later that day I watched a young girl who collects plastics to sell to a recycling operation pull an IV from her bag.

While the CHC was particularly alarming, I have also seen amazing and inspiring sights.  I have attended trainings of ASHAs on advanced childbirth counseling.  I have watched women in Self Help Groups (SHGs) learn about HIV/AIDS so they can go back to their communities and educate others.  I have met educated social workers who have dedicated their lives to their work and semi-literate peer educators who are dedicated to improving their communities.  There is much to be hopeful for, and I am slowly settling into my place within this mission of a healthy rural existence through the creation of visual heavy (for illiterate populations) presentations and handouts regarding HIV.  I will be field testing soon and have more to report then.

Living in the village has proven to be an experience in its own right, but in unexpected ways.  Power here is intermittent, literally shutting down the office for hours at a time.  My bedtime is therein determined by whether or not the power is on after sunset.  Nobody in the office (where I sleep, by the way) speaks English, and the community primarily speaks the local language (although most middle aged men and young people in general will know Hindi, but migrant laborers who work in tourism know some English).  The main market is about three city blocks (in US standards), and fields are just a 15 minute walk through the winding and narrow streets of the village itself.  People here are remarkably friendly in spite of the language barrier both on the streets and in the office.  The woman who sweeps our floors, who has better English than some of the workers here, invited me to dinner.  Perhaps because I’ve only been here for under a week, or perhaps because I am hopelessly naive, but as it stands I am quite happy and comfortable.

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