Please watch all 4 parts of this documentary series, covering healthcare systems in the US, UK, Switzerland and Australia. https
Please watch all 4 parts of this documentary series, covering healthcare systems in the US, UK, Switzerland and Australia.
Assignment Overview
· Case study: PIH ch. 7: “Swasthya: The Politics of Women’s Health in Rural South India,” by Suneeta Krishnan, pp. 128-147.
After reading the assigned text, compose a 400-500 word reflection and submit it to the Canvas discussion board.
In your reflections, address the following 3 questions.
1. What are the author's main messages/arguments? What is the main takeaway of this case study? What is the essential background information that we need to understand it? (2.5 points)
2. How does the case study relate to concepts from the course (including lectures, readings and videos)? Connect themes in the case study to at least 2 concepts from the course. Put these concepts in bold so that we can easily find them when grading, and be sure to explain or elaborate on HOW the case study illustrates, complicates or is connected to that topic. (4 points)
3. Share your personal reaction or stance on the issues developed in the case study. Has it changed your opinion on the topic? Does it relate to your own personal experiences? Does it connect to things you have studied in other courses, or articles you've been reading in the news lately? (2.5 points)
4. Proper citations (1 point)
Citations
You must include proper academic citation in your case study reflections. This is a good habit to get into generally. Visit this page for the general course citation guidelines.
· When referring to required course material, use a shortened version of the APA's author-date, in-text parenthetical citation system, e.g. (Marmot 2010). You can abbreviate our course textbooks to RGH and PIH, or use the case study author's last name. Be sure to spell the author's name correctly! Lectures can be cited by the number, e.g. (Ryan lecture 4.2). Videos can be cited by the primary speaker or a shortened version of the title, e.g. (Bad Sugar) or (Rosling).
· When referring to outside articles or sources, use the APA's author-date, in-text parenthetical citation system, e.g., (Washington Post 2021) and include a hyperlink or full citation to your original source at the end of your submission. Connecting the case studies to outside sources is always welcome, but be sure you are also
· You do not need to write a full bibliography for case study reflections.
,
Swasthya: The Politics of Women’s Health in Rural South India
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The Practice of International Health: A Case- Based Orientation Daniel Perlman and Ananya Roy
Print publication date: 2009 Print ISBN-13: 9780195310276 Published to Oxford Scholarship Online: September 2009 DOI: 10.1093/acprof:oso/9780195310276.001.0001
Swasthya: The Politics of Women’s Health in Rural South India Suneeta Krishnan
DOI:10.1093/acprof:oso/9780195310276.003.07
Abstract and Keywords This chapter looks at experiences providing health care to rural women in India. It shares thoughts about the quality of health care offered to women. The chapter also describes the establishment of the Well Woman Clinics, aimed at providing empathic reproductive health care, including information, counseling, and clinical services to women. Community health workers (CHWs) were trained to take a comprehensive, broadly defined health history and provide pre- examination counseling to help women assess what kind of clinical consultation they required and become acquainted with routine examinations.
Keywords: health services, reproductive health care, women's health, rural health, public health practice, health workers
In August 1997, three American students, including two of Indian origin, met at a newly opened cyber café in Bangalore city, India, to plan a women’s health program in Vijaygiri,i a rural community 350 kilometers away. Rajiv, whose brainchild the program was and who had raised funds for it, did not turn up for the meeting. The others decided to go ahead with their trip to Vijaygiri anyway. So, at the height of the monsoon season, the trio traveled to Vijaygiri to conduct a needs assessment for the program. I heard of their plans through a friend. In search of inspiration for my dissertation research, I decided to tag along. My father had passed away recently, and the sudden loss had left me drifting. I needed to find an anchor, a focus.
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At around 9 P.M., we boarded a “luxury” government bus that turned out to be anything but luxurious. Last-minute booking meant that we had the last row. After a few hours on a relatively straight highway, we started to climb up through the mountains. In the last row, even the most minor pothole tossed us high off our seats. And the rain! The rain came pouring down the whole night, leaking through the cracks around the edges of the windows. The next morning I stepped off the bus at the Vijaygiri bus stand damp and aching.
The bus stand was a patch of ground big enough to accommodate two buses and a few auto rickshaws. Coconut, arecanut, and other trees bordered the stand and houses crowded in on the sides. It was about 5 o’clock in the morning. Faint strains of the traditional Sanskrit morning chants played on a radio. A few auto drivers were standing around, yawning and stretching. Now that the rain had ended, the air was crisp, cold, and damp. Leaves on the trees were fresh with dew and (p.129) rain. Ah, how peaceful, how idyllic were those first few moments in Vijaygiri after the hustle and bustle of Bangalore. “Perhaps here I will find a dissertation topic and peace after the turmoil of my father’s death,” I thought.
No one was there to meet us, so we approached an auto rickshaw driver and asked to be taken to the hospital. We drove through what looked like the main road of the town, up a hill and around a corner. There at the top of the hill was a sprawling pink building. To the left, by the side of the parking area, was a badminton court. People slowly moved about with toothburshes, towels, and flasks. No one seemed to notice us. We wandered in through the main entrance and reached an inner courtyard with hallways going left and right and stairs going down. Just as I began to feel a bit frustrated, we saw a tall man, maybe in his fifties, walking toward us from the corridor on the left. He carried himself with an air of authority, but at the same time his smile was open, welcoming. He reminded me a bit of my grandfather. It was Dr. Vasan, the chief medical officer of the hospital.
Rajiv and the students I was with had worked out the broad goals of the project with Dr. Vasan. The idea was to extend the mobile clinics that the hospital was conducting to make outreach more regular and to recruit a group of local women to engage in health education. The initial mission was to “empower women with information and other tools to make and act upon health care decisions.” I was wary of the fact that the project did not have an explicit ideological or theoretical orientation. Further, there had been no discussion about roles and responsibilities—of the student group, the hospital, or the health workers we would recruit. I was apprehensive that the undertaking might turn out to be a haphazard student project rather than a formal program and about being saddled with responsibilities that I had not had time to fully comprehend. I was already a year into my “all but dissertation” status in the doctoral program in epidemiology at the University of California, Berkeley, and was conscious of
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the need to stay focused on completing the dissertation. I was also committed to a project that would keep me linked to my childhood roots in India—a desire that had shaped the focus of my undergraduate and graduate studies in the United States. Thus, quite quickly, I became the group’s point person.
Later that first morning, after we had showered and dressed, we met Dr. Vasan at the canteen, a low-roofed annex to the main hospital building. As we devoured the iddlis (steamed rice cakes), chutney, and sweet hot coffee served in 2-inch- high steel cups, a doctor who looked to be in his early thirties greeted Dr. Vasan with respect and then turned to us with an excited smile.
“So these are the Americans.”
“This is Jagan,” introduced Dr. Vasan. “He has been running the hospitals’s nursing program and the community outreach.”
Dr. Jagan seemed excited and enthusiastic about meeting people interested in his line of work. We began to discuss what our role at the hospital would be, and once our conversation was under way, Dr. Vasan excused himself to begin morning rounds and left us to our discussions with Jagan.
(p.130) A few days later, in an airy, spacious office of the hospital, I met with Dr. Jagan and the honorary secretary of the hospital, an elderly, sprightly man who had retired from the banking sector. Jagan seemed far more relaxed in the presence of the secretary than in that of Dr. Vasan. In fact, he was in his element.
“What we need is mass education,” he announced. “Now is the time to start. I have 20 girls finishing the nursing course this month.” Dr. Jagan had been running a 1-year training program for nursing assistants, who were simply called nurses. If we did not move fast, we would lose the opportunity to recruit a few of the graduates. Most got hired by nursing homes and clinics in the district and neighboring districts. Once they got jobs, it would be difficult to recruit them for our project. And once we hired them, we would need to initiate training as well.
At first I was reluctant to rush to action, hoping instead to take our time in developing a solid plan. However, I caved in.
“We’ll interview the candidates tomorrow,” announced Dr. Jagan.
The secretary seconded the proposal. Dr. Jagan recognized the importance of identifying young women with a commitment to staying back in their home communities, with an interest in working on women’s health. But I learned from him that in order to accomplish our goals, we had to work very strategically
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In her more recent work, Suneeta Krishnan has been operating out of urban clinics in Bangalore, India, interviewing young women about their marriages, economic situation, and sex lives. (Photo: Jason Taylor for Time.)
within the hospital. We had to bring on board the authorities, like the secretary, and the staff, like the head nurse, by trying to work on terms acceptable to them.
On one of my early trips, I drove back to Bangalore with Dr. Vasan and his wife, Dr. Sarojini. Dr. Vasan was in a nostalgic mood and eager to confide. We spoke
(p.131) at length about the hospital during our ride to Bangalore—about the 10 years they had spent struggling to establish the hospital, and about Dr. Jagan. I learned that Jagan was a native of the town, trained in Ayurvedic medicine. “We sent him to get training in anesthesia. The main problem with him is that he doesn’t have confidence. He doesn’t focus,” Dr Vasan said.
“You know, for even a little thing, he will send people for an x-ray, an electrocardiogram,” added Dr. Sarojini.
Dr. Vasan continued in a resigned voice, “I manage with him. His main strength is public relations. He will be good at helping you with the training of these health workers and talking to the panchayat [village council].ii He’s good at handling politics. But I will come to the weekly clinics myself.”
In contrast with what Dr. Vasan had told me, Dr. Jagan seemed very confident. As the project evolved, the student group and the community health workers (CHWs) relied on him to negotiate with the hospital authorities as well as with local village authorities like the panchayats and local landlords. He had the ability to connect with people and to speak in ways that they could identify with. I felt that ultimately it was Dr. Jagan who understood the project—and in many ways it was his project: it emerged as an extension of his nursing training program and his community outreach work. For years, before Dr. Vasan and Dr. Sarojini had joined the hospital, Jagan would hitch rides with taxis and jeeps going out to the villages to offer health care and information. He had a strong commitment to social service, which made him a natural leader for our project.
Our new recruits, the CHWs, participated in a 3-month training program in community health. During this time, Jagan lobbied with wealthy families and local panchayats to donate space for the CHWs’ health centers. In January 1998, we launched health centers in six villages within a 30 kilometer radius of
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Vijaygiri. Jagan and Dr. Vasan planned a grand launch—a large multispecialty camp. Camps are a common strategy used in India to promote health-care access as well as utilization of particular kinds of health services such as sterilization or screening. A number of doctors we met at Vijaygiri and Bangalore who were involved in community health all felt that the most effective ways of establishing oneself in the community was by providing basic medical care through camps and outreach clinics. Dr. Vasan and Jagan too felt that this was crucial.
The day of the launch, Jagan was extremely tense but in charge. He paced up and down, checklist in hand, overseeing the packing of equipment and materials. We left the hospital as a convoy of four vehicles. The hospital van left at around 8:45 A.M. with a team of student nurses, laboratory technicians, and equipment. Jagan followed in his car with the CHWs, his wife Ila, his daughter Ashwini, and Ashwini’s puppy Amitabh, named after a famous Bollywood actor. I followed in a jeep with Dr. Vasan and a few other doctors.
The first center, located in hilly estate country, was being launched at the village farthest away from the hospital. It consisted of two rooms within the village government office at the foot of a hill. Areca nut trees dripping with black pepper (p.132) vines and sweet-smelling coffee bushes in bloom grew on the slopes. Closer to the summit were the neatly cropped tea plantations.
By the time we reached the site at about 10 A.M., at least 50 people had gathered. The majority were women, some with children. The panchayat officials, registers and pens in hand, seemed extremely organized, as did several community volunteers. There must have been a team of about 20 organizers and a total of about 8 clinical specialists at the camp. It was 10:15, and a festive atmosphere prevailed. Hindi pop music blared on the speakers. The panchayat officials decided it was time to begin.
The next thing I knew, the owner of a local tea estate who was sponsoring the day’s program was announcing my name, and I was led to the stage by one of the camp volunteers.
With a dry mouth and a racing heart I walked to the microphone. Over 100 people had gathered by then. Dr. Jagan introduced me: “Now, Mrs. Suneeta Krishnan will say a few words about Swasthya. She is one of the dedicated students who has come all the way from America to work with us.”
I reminded myself that I was the “laudable American” and could do no wrong. Braced by this thought, I launched into my speech, in English: “Today’s program is a true representation of what Swasthya is trying to accomplish: local communities, the hospital, and the Swasthya team working together to promote health. We hope this partnership will be a long and successful one.”
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Dr. Jagan stepped up to translate and then launched into a few of his own remarks: “Our goal is to provide not merely treatment but also health education. Illness prevention is the goal.” Throughout the life of the project, he would repeatedly emphasize this goal.
Finally, after what seemed to be an eternity, the speeches came to a close. The panchayat president (head of the village government) kicked off the camp by requesting all those who wanted a health checkup to register. In minutes, a long queue of men, women, and children formed at the registration desk in front of the panchayat office. Three young men, panchayat volunteers, sat at the registration desk and asked each individual to identify which specialists he or she wanted to consult. I watched the proceedings for a few minutes. There were many women in line—dressed in their holiday finest, with flowers in their hair and colorful glass bangles on their arms. Some had babies on their hips. A few were chatting and joking; others looked tense.
“Do you live here—in this village? It looks like the entire village is here!” I asked a group of women in broken Kannada, the local language, peppered with Tamil and Malayalam, the two languages that I spoke growing up in Kerala, another South Indian state.
“No, we are from the tea estates up over the hill behind you. We had to walk nearly 8 kilometers to get here,” they replied. Behind me was a steep hill, crowded with tall, lanky silver oak trees whose leaves glistened like silver in the sun. The district had many large estates tucked away at the tops of remote hills. Some provided (p.133) basic primary health care, but in general accessing care was a considerable challenge, given the terrain and the distances involved.
I was with another Indian-American student, Preeti, who was taking about 6 months off before starting medical school in the United States. For us, this first camp was an opportunity to begin understanding the range of health problems that women had, how they talked about them, what they did, and how local clinicians responded. We decided to split up, observe, and take notes.
I continued to stand by the registration desk to observe the requests being made. Once the women realized that I could speak a little Kannada, they started to talk.
“My two children and I walked 10 kilometers across the paddy fields over there,” a woman told me, pointing to the valley down below the panchayat office. Green fields beginning to turn a golden brown, approaching the winter harvest, extended for several kilometers ahead. Near the horizon I could make out a settlement. At the camp, we learned how important the local terrain was in shaping women’s access to care. This region is heavily forested and mountainous. Many villages are tucked into the hillsides and surrounded by dense vegetation. Because of heavy rainfall, there is extensive paddy cultivation
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in the valleys where “villages,” consisting often of just a handful of homes, are separated by kilometers of fields. Distance and lack of transportation were therefore important barriers to health-care access.
“We even missed a day’s pay to come to the camp! Management is like that— they won’t even give us a day off if we are sick,” said one young woman.
“Sixty kilos we pluck. Is it any wonder that we have back pain and white discharge?!” questioned another.
Many of the large estates are mandated by law to provide basic amenities such as health care and primary education. However, most of these clinics are run by male doctors. Doctors and women are uncomfortable with physical exams; therefore, if a woman does seek care for a gynecological problem (which she may not), treatment is usually based only on reported symptoms. Without the estate doctor’s permission, women would incur leave without pay if they needed a day off to seek gynecological care from a woman doctor, who might be anywhere from 10 to 30 kilometers away.
One woman explained, “When we to go to the town to see a lady doctor, we have to spend so much—5 rupees bus charge and another 50 rupees to the doctor. And then the medicines.”
Even when health care was accessible, as in the case of our camp, the culture of silence around women’s gynecological health was so pervasive that women would not reveal their problems. The fact that we were requiring everyone to publicly state which specialist they wanted to see was clearly not conducive to making women comfortable about indicating gynecological concerns. Further, we had young men sitting at the registration desk noting down this information. This did not strike me immediately. But as I stood there for 5, 10, 15 minutes and found that so (p.134) few of the women were stating gynecological problems and seeking consultations with the gynecologist, I began to become suspicious.
My uneasiness was confirmed when I struck up a conversation with a tall, thin woman who looked to be in her thirties. She seemed tense and apprehensive, wringing the edge of her sari, scanning the crowd. I approached her with a smile and welcomed her to the inauguration of our new health center.
Bharati was her name. I described Swasthya’s services and focus on women and I asked her what concerns brought her to the camp.
“Headaches,” she said.
“Have you been having any other problems?” I asked as we waited for her turn to register.
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“No,” she said uncertainly. Given her hesitation, I engaged her in some lighter conversation. “So, how many children do you have?”
“Three—two girls and a boy.”
“Have you brought them also for a checkup, or did you come on your own?”
“I came on my own.”
“So tell me, how is your health? What kinds of problems do you have?”
She moved closer to me, and while keeping her eyes downcast, confided, “I have been bleeding a lot, more than what is my usual, and throughout the month.”
I asked how long it had been happening.
“It’s been more than half a year now. But the estate doctor said not to worry, he didn’t even need to look at me. He said that it happens to women at my time of life and that it would stop soon. I am waiting, and yet I feel so weak. Every day is more difficult.”
At 35, Bharati seemed young for menopause. I felt that her symptoms merited an examination, if not some extended treatment, and I was angry the estate doctor had not even examined her. I was sure she would benefit from an exam from the female gynecologist at our camp.
“Oh, there is really no need,” she said, “I am sure I will be feeling better soon.”
We had been speaking with a friendly rapport, but I reverted to playing the health professional role, and after a few more words of encouragement, Bharati nervously agreed to an exam. I completed her registration and then accompanied her to the line in front of the gynecologist’s room. I returned to the main registration queue to continue talking to others.
I saw Jagan nearby: “You have to tell the men at the registration desk to ask all the women if they want to see a ‘lady’ doctor,” I said anxiously. “The women are too shy to ask and they’re going to miss out on an opportunity to see the gynecologist!”
I watched understanding flash across Jagan’s face. Immediately, he headed to the registration desk to make our request. This approach worked much better. The doctors’ consultations went on all day.
A typical exam took place like this: The doctor is sitting behind a wooden desk. The nurse is standing, attentive, by her elbow. The patient enters and stands, (p.135) waiting to be acknowledged. She moves to sit on a stool by the side of the desk when the doctor motions her to do so. “So what is the problem?” the doctor asks, without lifting her eyes from the case sheet on the desk. The patient
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describes her symptoms and the doctor orders her to the examination table, chiding her if she does not cooperate by getting into the lithotomy position to facilitate a pelvic exam. Occasionally, if the patient resists out of fear, her legs are pried apart.
Later, we noticed the marked difference when doctors treated women whom they perceived to be their social “equals,” that is women of an upper caste. Upper-caste women were welcomed into the consultation room with a smile. Eye contact would be made and explanations given. The women would be put at ease before the examinations began.
The most common problems that women at the camp reported were white discharge, excessive bleeding during menstruation, and missed periods. The doctors examined the women who complained of white discharge (some with a speculum and some without), but most of the time they could not find anything wrong and would either prescribe ayurvedic medications or order a blood test. The doctors did not offer much advice to the patients. Mostly, they simply prescribed medications.
The experience of Lakshmi, a thin, diminutive 28-year-old woman who worked on the tea estate, was illustrative of the lack of dialogue during medical consultations. She came to the gynecologist because she had still not started menstruating. Dr. Sarojini took her into an inner room for an examination. Shortly after, she returned to tell us that Lakshmi had poorly developed female sexual organs (immature breasts and poorly developed genitals), probably due
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