JUST GIVE A THOUGHT...

What are the images that come to your

mind when you hear the words safe motherhood? The images must be so different for different people, from different cultures, communities and countries. But all, somewhere, tied together with a white ribbon. Safe Motherhood Day in April raised the issue, enhances the discourse, and also perhaps heightens the need to do something so women dont have to die of preventable causes while bearing and birthing a child. This issue of Kushal brings to you a story from Navsari in Gujarat, of the positive impact of collective engagement between grassroots political leadership and government, communities and civil society organizations on saving mothers lives. There are so many narratives of positive experience, so many examples of what works, or worked. Across communities and involving a diversity of stakeholders. The point is, averting maternal deaths is a major public health agenda, and success will not be rapid, thats a surety. That, however, need not stop anybody from trying, in whatever way possible, to help make a difference. So, whether you wear a white ribbon or not, just devote a little bit of your time to thinking about the why and the how of women who lose their lives unnecessarily, as they do when maternal deaths happen. Half a million women die this way each year, one each minute, somewhere in the world. This is a reality that can be changed through the power of communities. Theres so much change thats happened through the work of committed individuals and collectives, and one such heart-warming story is featured in Kushal this time a story of district level networks of people who live with HIV/AIDS. The persuasiveness of first-hand experience is unmatched in its ability to transform societies and this narrative shares the experience of getting care, treatment and support to remote villages and people far from the action. So, just give it a thought. Dr. Subhadra Menon Head, Health Communication & Advocacy Division

IN FOCUS
MAKING WOMEN MATTER: THE NAVSARI WAY By Swapna Majumdar
When Jamku, a 23 year old tribal woman from the Vansada block of Navsari district, Gujarat, became pregnant she didnt know of her entitlement to free antenatal care and postnatal care at the Primary Health Centre (PHC) under the National Rural Health Mission. Neither did the community Auxiliary Nurse Midwife (ANM), who forms the backbone for delivering free basic and comprehensive obstetric care to rural women living below the poverty line, inform her. The ANMs reluctance to inform Jamku was not because she was poor and illiterate but because she was unmarried. These facts came to light when an Ahmedabad, Gujarat-based NGO, the Centre for Health Education, Training and Nutrition Awareness (CHETNA), working on health and womens empowerment, was conducting a meeting in Jamkus village in June 2007. Although unwed mothers were socially accepted in Jamkus community, the ANM was unwilling to register pregnancies of unmarried woman as she was unable to provide the name of their husbands. Thus, Jamku too was not registered and did not receive antenatal care. When Jamku went into labour, CHETNA workers rushed to her house and asked the family to shift her to a public health facility. Her mother was reluctant to do so in the first place, but after being told of the urgency of medical care and attention to save Jamku and her childs life, the family agreed to take her to the hospital. Jamku was fortunate, as the CHETNA workers intervened on time to save her life. However, there are millions of women like Jamku in India who die unattended or due to lack of appropriate care. In 2009, Human Rights Watch (HRW) estimated that, of every 70 girls who reach reproductive age in India, one will eventually die because of pregnancy-related complications, childbirth, or unsafe abortion compared to one in 7,300 in the developed world. There are 450 maternal deaths in India per 100,000 live births, which are higher than 120 other countries including India's neighbours such as Pakistan, Sri Lanka, the Maldives, and China. HRW attributed maternal deaths to delay in identification of complication and taking timely action, in reaching the appropriate health facility and, in initiation of treatment at the health facility. But these factors, identified as prime reasons for maternal mortality, can be decreased and millions of women who die can be saved if appropriate actions are taken, believes Indu Capoor, director, CHETNA. This, she said, had been shown in a recent pilot project undertaken by CHETNA in collaboration with the Health and Family Welfare Department of the Government of Gujarat, and the Academy for Nursing Studies (ANS), Hyderabad, in Vansada and Chikhali, two tribal blocks of Navsari district where poor access to maternal health services and information could be fuelling high maternal mortality.

Initiated in 2006, the three-year Public-Private Partnership (PPP) has led to significant improvements in the health indicators within the project implementation area. According to project data, of the 776 deliveries that took place between June 2008 to March 2009, not a single maternal death was registered. Data from the pilot also showed an increase in institutional deliveries from 57.7 per cent in 2006 to 82.3 per cent in 2009 in Vansada block, and from 75.6 per cent to 97.4 per cent in Chikhali block. The number of beneficiaries under Janani Suraksha Yojana had risen from 493 to 2113 in Vansada block and from 400 to 2431 in Chikhali block in the period 2006-2009. The intervention designed by CHETNA included training and sensitising panchayat members, Traditional Birth Attendants (TBAs) and Self Help Group (SHG) members to recognize pregnancyrelated complications and ways to take timely decisions and seek obstetric health care to reduce the delays in reaching appropriate health facilities and initiating treatment. Interventions like regular village meetings, training the community to dial 108 (ambulance services) and sensitising the TBAs SHG members as link persons between the village and health facility has helped in ensuring community participation and has played a key role in increasing institutional deliveries and accessing maternal health services at village level, said Dr S.K Patel, Block Health Officer, Vansada. Dr Akhilesh Pandey, quality assurance medical officer, District Panchayat Office, Navsari, attributed this improvement to the collaborative efforts of all stakeholders working in the community. Each of us knew what we had to do. This was very helpful in identifying and resolving the problem, pointed out Pandey. Although Maternal Mortality Rate (MMR) of 160 in Gujarat is lower than the national average (Sample Registration Survey 2004 - 06), there are block-wise variations in Navsari district has, especially among tribal blocks, in accessing maternal health services from the public health system. The CHETNA baseline survey in 2006 found that non-institutional deliveries constituted almost 50 per cent of the total deliveries conducted in the tribal blocks. Dais conducted about 90 per cent of the home-based deliveries. Only 15 per cent women across the blocks received postnatal care within 72 hours of delivery, which is considered to be the most crucial phase as most of the maternal deaths occur during this period. The CHETNA team faced several challenges in executing this programme. A majority of the panchayat members had never visited the local PHC and issues related to health were low on their priority list. They had inadequate information about maternal health and their role in helping people access essential health services at the village level. We had heard about an ANM but didnt know what her exact role was. So, we didnt make any significant efforts to coordinate with anganwadi workers (AWW), Accredited Social Health Activist (ASHA) or ANMs to improve maternal health scenario at the village level, said Sureshbhai, panchayat member, Dhakmal village. The several training sessions held for panchayat and SHG members provided information about maternal health service entitlements, including the Chiranjeevi scheme wherein skilled attendance at delivery and emergency obstetric care is available free of cost to all women living below the poverty line. The role of ANMs, AWWs and Panchayati Raj Institution (PRI) members in making the services accessible to the community was also shared. They were taken to visit the PHC sub-centre and demonstrations were given on how to call 108 through the Emergency Medical Response Service (EMRS) to get pregnant women transferred safely from the village to the health facility.

The Gujarat government supported and financed the production of posters, calendars booklets and other information material, which were then disseminated to create general awareness about importance of accessing maternal health services especially during Mamta Diwas (Maternal and Child Health and Nutrition day).The Gujarat government has assigned a particular day as Mamta Diwas to be observed once in a month in each village to carry out comprehensive nutrition and health education, along with other services. CHETNA team members were present at several such events during the project period to guide the AWWs, ASHAs, TBAs, PRI and SHG members and members of milk cooperatives in accessing entitlements. Meetings were also organized to facilitate interaction between the community, the block development and medical officers; information from the field was shared with the block, district and state level officials to develop an action plan to strengthen knowledge among and action by TBAs, panchayat and SHG members. Review and practice of midwifery skills and sensitization sessions on gender issues was also provided by ANS. The ANMs, held discussions with dais, village leaders and panchayat members and conducted antenatal clinics, immunization clinics, counseling sessions and health education programmes. They (the ANMs) also held meetings with pregnant women on gender issues and problems of sex selection and discrimination, took classes and demonstrated postnatal and newborn care to dais. We focussed on participatory sessions and on community partnerships, stated Prakasamma, director, ANS. Milk cooperative member Ramanbhai shared how they shoulder the responsibility of monitoring ASHA workers to ensure she makes a visit and also makes a report so that the Medical Officer/nurse sees it. Maheshbhao, sarpanch, Mohuvas village, revealed that they learnt to work as a team after the training imparted to them. In March 2009, this partnership facilitated the transfer of 200 pregnant women to health facilities for institutional deliveries. According to CHETNA, the initiative, implemented in 60 villages, has cost Rs. 33,815 per village per year, thus making it affordable to replicate. The training of Village Health Committees in 21 districts of Gujarat by members of the Jan Swasthya Abhiyan, the coalition of health NGOs, is expected to begin soon. Considering the financial constraints faced by many states, it is not just the reasonable cost involved that makes this intervention significant, but its collective engagement of grass roots political leadership, government, community and civil society to save lives. Swapna Majumdar is a senior writer and journalist specializing in issues of human development, based in New Delhi.

DRINKING WATER: FROM RIGHT TO REALITY

The lack of access to drinking water and sanitation are a seriously under-played and passive human rights issue in India and could be true of other countries as is evident from heightened global advocacy that unmet water needs must no longer play second fiddle to other priorities (UNICEF, 2010). That is hardly debatable, but millions of Indians have been struggling just for water, to drink or for other uses. Although recent claims reveal that drinking water supply has improved, a reality check is strongly recommended and it is as simple as a quick walk through the crowded, dark galis (lanes) of your neighbourhood slum. Far from these ordinary neighbourhoods with their everyday, persistent, gnawing problems, global discourse focused on the Millennium Development Goals stridently declares how Goal 7, target 7c aims at halving the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015. Meanwhile, the statistics paint a bleak picture. - World Bank estimates that 21% of communicable diseases in India are related to unsafe water [1]. And yet, close to 20 million Indians in rural areas do not have access to safe drinking water [2]. - Census of India data reveals that the coverage of safe drinking water supply has been increasing consistently * urban coverage has increased from 75% in 1981 to 81% in 1991 to 90% in 2001 * rural coverage has increased from 31% in 1981 to 56% in 1991 to 73% in 2001. It is important to note here that this data is calculated according to a methodology which assumes that if a household has access to drinking water from a tap, tube-well or hand-pump within or outside the premises, the family is considered as having access to safe drinking water [3]. However, these statistics may not throw adequate light on the dilemma of the poor who struggle against disproportionate distribution of water. Therefore, it is also necessary to view this against a backdrop of constrained, under-managed, or mismanaged services and systems. If it made any difference or offered any solace to those who go without or survive with minimal water each day of their lives, and have a special routine that is unique to them -- it is now recognized that every individual has a right to these basic services. India is a signatory to international human rights treaties wherein the right to water and sanitation has been explicitly referred to in various ways. : Article 14 2(h) of the Convention on the Elimination of all Forms of Discrimination Against

Women, 1981 states ...to enjoy adequate living conditions, particularly in relation to housing, sanitation, electricity and water supply, transport and communications.; while the Article 24(1) on the Convention on the Rights of the Child, 1990, recognize the right of the child to the enjoyment of the highest attainable standard of health and shall strive to ensure that no child is deprived of his or her right of access to such health care services. (2) State Parties shall pursue full implementation of this right and, in particular, shall take appropriate measures to provide adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution. The Indian judiciary has used creative reasoning to include right to water and sanitation into the fundamental Right to Life (guaranteed under Article 21 of the Constitution of India). In a landmark judgment, Municipal Council, Ratlam vs. Vardhichand (AIR 1980 SC 1622), the Supreme Court held that it is the duty of the municipal council to construct sufficient number of public latrines and to provide water supplies and scavenging services in an area. The Court also held that budgetary constraints do not absolve a municipality from performing its statutory obligations to provide these basic facilities. In this case, Justice Krishna Iyer observed that decency and dignity are non-negotiable facets of human rights and are a first charge on the local self-governing bodies. But do legal rights walk their talk? And then theres the sticky issue of services and their supply the walk through less privileged urban areas can rapidly reveal the gaps. Heres how people collect drinking water in Chandbag, Shahadra, Delhi. This water pipe is located in a drain, next to the garbage disposal area. We usually do not boil water that is collected from this water point, says a resident from the gali. To the woman who collects precious water for her home and family, theres only one kind of water, and it must be collected. This reflects the current status of access to water at Shahadra (located in the North-East district of Delhi). Sanitation is also a major concern in the area. Open plots and drains are often used as garbage disposal grounds. Residents say that they are forced to clean blocked drains themselves, since the government appointed safai karamcharis (cleaners) do not clean their areas regularly and have not been made accountable. Claiming ones rights could be a major catalyst. Dhanno (left in the picture) who is a resident of Delhi says Jagrukta hi samadhan hai (Awareness is the solution). Ammaji (middle) says that even at her age, she is willing to go and file complaints to the municipal authorities if others in the community are willing to accompany her. [1] Accessed from http://water.org/india/ on 6 September 2009 [2] Indira Khurana and Richard Mahapatra. Right to water and sanitation. WaterAid India. 2009 [3] Shital Lodhia. Quality of drinking water in India: Highly neglected at policy level. Centre for Development Alternatives. October 2006

PUBLIC HEALTH WATCH DELHI PLANS PUBLIC HEALTH RESPONSE FOR 19th COMMONWEALTH GAMES
The Department of Health Services (DHS) of the Delhi Government is preparing ahead of the Commonwealth Games (CWG) to address health incidents that may take place due to injuries and disease outbreaks or seasonal spread of illness. This includes a health promotion drive and an emergency preparedness plan to tackle such occurrences. On April 8, 2010, Shri Suresh Kalmadi, Member of Parliament and Chairman of the CWG, Delhi 2010 Organising Committee, flagged off the 10th Perfect Health Parade. The parade promoted a clean, green and hygienic Delhi for the Commonwealth Games and focused on sensitising doctors and the public at large about the propensity of health hazards from crowding, preventive measures and cure. Efforts are being made to further capacitate these doctors for offering services to participants and support staff at the upcoming CWG. Five hundred medical doctors and 200 paramedics are being trained to take on the load, according to the Delhi Government . DHS has called upon the services of 200 paramedics, including masseurs, physiotherapists and support staff, besides volunteers who will form part of the health team to take care of visitors at the Games. Prior to the event, masseurs will be oriented to understand sports-related injuries and treatment available outside India. This capacity building initiative aims at equipping them with skills that they may be required to use. Three major government hospitals GB Pant, Ram Manohar Lohia and the All India Institute of Medical Sciences will be the key points for hospital-based care. Additionally, there are plans to set up over 40 special clinics in various parts of the national capital to provide medical facilities to participants of the event. It must be noted that health promoting habits rarely emerge overnight and such drives may only be a drop in the ocean, but the fact is that the CWG may just be the right opportunity for the DHS to strengthen the public health system.

A CALL TO STRENGTHEN PREVENTIVE ACTION AGAINST CHRONIC DISEASES

Turn around and face outwards was the take-home from the 7th Oxford Health Alliance Summit, held on 19-20th April, 2010 in New Delhi, as a platform to share experiences and strengthen collaborative practice to respond to the obvious increase in chronic diseases in developing countries. In order to draw attention to this concern as well as position prevention as a public health priority, the Summit brought together clinicians, researchers, epidemiologists, programme managers and public health specialists as well as communication experts, academics, government representatives, health professionals, young people, NGOs and corporate executives to generate a collaborative approach to solving problems, with new thinking. The meeting was hosted by the Centre of Chronic Disease Control (CCDC), New Delhi, and the Oxford Health Alliance (OxHA), London. That chronic disease -- heart disease, cancer, Type 2 diabetes and chronic respiratory diseases is a phenomenal part of the worlds overall public health burden, is a well-known, well-studied and documented fact. According to the Lancet (Combating Chronic Disease in Developing Countries, June 11, 2009), more than half of all deaths worldwide, 80% of which occur in low and middle income countries, are caused by these health conditions. Needless to say, economically and socially challenged sections of the population naturally bear the brunt of the impact since they resort to distress-financing during sickness and thereby get further pushed into poverty. Meanwhile, Indias epidemiological transition from underweight to overweight has been effected by shifts in diet and in physical activity patterns, particularly in the last few decades. People seem to be consuming a diet high in saturated fats, sugar and refined foods but low in fibre. Chronic diseases are increasingly affecting a younger age group accompanied by an onslaught of globesity (a relatively new term used to reflect the alarming rise in obesity across the world). It is now recognised that childhood obesity is an emerging problem among urban Indian children. It is also evident that increases in childhood obesity may be a major contributor to the adult obesity epidemic. The hazards of sedentariness are now becoming big. According to a WHO report (2004), among the leading causes of global mortality and burden of disease are physical inactivity along with high blood pressure, tobacco use, high blood glucose, overweight and obesity, high cholesterol and alcohol use. The report estimates that these causes and other factors have contributed to 59 million global deaths in 2004.

The New Delhi Summit also sought to break the silos of prevention and practice. As Dr. Nikhil Tandon, Associate Professor at the All India Institute of Medical Sciences, New Delhi put it, There is a need to understand what is changeable and reframe ones thoughts on diabetes. The evidence supports the life course approach suggested by Dr. D. Prabhakaran, Executive Director of CCDC to chronic diseases from early infancy to old age, which requires communities to understand the need to change. Effective strategies include creative health education and entertainment alternatives that need support from civil society organisations and Resident Welfare Associations, in order to wean young people away from tobacco use and promote fitness. Healthy sidewalks, green areas in cities maintained in partnership with Resident Welfare Associations are options that need to be implemented if exercise is to gain universal acceptance. Health literacy defined as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions, plays a critical role in preventing chronic diseases (Rootman et.al. 2007). In an article that appeared in The Hindu newspaper (June 2009), Prof. K. Srinath Reddy said, health literacy is essential to empower individuals, families and communities to protect, preserve and promote their health. Not only does this refer to formal literacy which would equip men and women to read and understand labels on medicine bottles, prescriptions and avoid being confused by instructions received from medical providers, it also implies an engagement with communities to discuss and evolve an empowered understanding of individual and community health. Commitment at the policy level and a wider understanding that promoting physical activity is a costeffective and universally accepted prevention pathway would be critical. Policymakers can make an enormous difference to improving the well-being of people. However, in order to do so, they must have usable knowledge that is accessible and understandable. Often, timeliness is of the essence, so in order to support informed decision-making, there must be evidence. Therefore, the translation of relevant and credible research to policy and communication assumes immense importance. The Summit stressed the importance of translational research and of involving policymakers from the outset to create an urgency around health issues, while taking optimum advantage of opportunities (from policy level to communities). All of this means that data from the research fraternity must also move into the public domain, in languages people can understand. Eddie McCaffrey, New Media Director of the OxHA said turn around and face outwards, as his message to researchers, clinicians and the community of practice in public health during the Summit. Through the clamour of data, studies, documentation and reports, there is also a need for a million voices to tell the story of chronic diseases, using social networks and blogs. So, a new avatar of what is commonly known as mass media could very well be just the masses talking to one another! And talking or communicating helps. Theres no doubt about that, especially as the major catalyst for behaviour change, the holy grail of public health.

FIELD DIARY
STRENGTHENING LIFE SKILLS AND LIVELIHOODS TO REACH HEALTH
In her latest avatar as a student of the PG Diploma in Public Health Management at the Indian Institute of Public Health, Dr. Ivonne M. Sangma, a doctor at the Zikzak Block Public Health Centre in the West Garo Hills of Meghalaya shares her experience of walking with her classmates through the lanes of a slum to observe how economic empowerment may improve entitlements to health. An early start to the day saw the entire batch of 29 students set off from the hostel in a bus to Tigri, an urban slum in Delhi, as part of a field exercise. The focus of our visit was to get to know about the activities of Mamta - Health Institute for Mother and Child, an NGO addressing health needs of the poor and marginalized sections of the urban population in this area, and also to understand how opportunities and challenges present themselves in creating an enabling environment for improved health outcomes. Upon arrival at their Training Centre, we were introduced by our faculty to the staff and volunteers, who then collectively briefed us on the inception and evolution of Mamtas interventions at Tigri since 1990. The NGO simultaneously works on multiple projects at Tigri in the areas of Maternal and child health (MCH), immunization, youth-friendly health services, gender, mahila panchayat empowerment and more. We soon found out about Tigris long history of high infant and maternal deaths which had seen a gradual decline through Mamtas persistent efforts, and yet there was a long way to go. Government health services, we were informed, and I drew parallels with the problems of access back home, were underutilized and perceived to be limited in their capacity to successfully cater to the numbers. After a comprehensive introduction, all the students were divided into groups and our group was given the opportunity to visit the MCH clinic, where we interacted with volunteer community members (both male and female) who have been trained to forge and promote networks of information and services, on a performance-based honorarium. These volunteers conduct meetings with the women of the slum and form a Community Based Organization (CBO). From within the CBO, women with leadership qualities are selected and trained to be master trainers, who in turn go back to the community and conduct either one to one or group interactions through role plays, story telling or flip charts, to sensitize mothers and make them understand the need to have safe or institutional deliveries and also the importance of immunization. One of the interesting approaches we learnt was that the CBOs do interact with not just the usual suspects; pregnant or new mothers but also with in-laws, husbands and couples separately, and also have structured one-to-one sessions with local dais, where they stress the importance of observing the 5Cs while conducting a delivery (in case mothers are unable to or consciously do not go to a hospital). The CBO has also enabled logistical networks that would stand the test of emergencies, by sensitizing auto rickshaw drivers (as the mode of transport that is easily available and affordable) in order to create a roster for use by pregnant mothers. After this interaction we walked through the lanes of Tigri

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to meet the master trainer for Block A, and I was surprised to find a bright, young, unmarried girl who shouldered the responsibility of mobilizing women in her block. They would then collectively reach pregnant mothers and even arrange for them to be escorted to the hospital for safe deliveries, and reinforce the importance of immunization. Tracing our way back from Block A to the Training Centre, we visited the Gender Resource Centre where young women aged 15-35 years were being given training in embroidery, stitching and other such vocational skills. We were told by their instructor that the women were either school drop outs or young mothers who were not only given free life skills but were also being informed on reproductive and sexual health and rights, nutrition, legal awareness and benefits of self-help groups (SHG). At the same time and in the same room, children of the community were being taught, either in remedial classes for school or continuing education for drop outs. In the room adjacent we were amazed to see a free-of-cost beauty training programme in progress, where for two hours a day for six months, the trainers would be able to share information with community members. I was very keen to know the rationale behind imparting beauty training. What has it to do with health of women was a question that arose in my mind? Though the idea was to make women financially independent or earn extra income for the family, there was no certainty that this additional expenditure would be on improving the health of the family and community at large. The training period was however, also used to inform them of issues regarding sexual and reproductive health and rights, nutrition, legal awareness and health related concerns were also addressed. We were told very enthusiastically by the trainees that some of them have even found employment at nearby parlours and this had been made possible for them because of the opportunity given by Mamta and support from their spouses. A self-help group (SHG) called Naya Savera or new dawn was also started as a source of microcredit by ten women with a contribution of Rs. 100/- per month. In times of need, women of this group can borrow at an interest rate of 2% a month and women have been found to be prompt in repaying the money. What I see here are small and easily replicable ways in which the confidence of the community in itself and in the programme can be asserted. From our visit, I learned that empowering women with knowledge and skills to address their health and development needs is a useful first step towards community engagement with health issues. By creating a CBO, women within the community worked for the community and so all efforts may be sustained with the shared vision of continually working for the betterment of health. Through community participation, they are developing health- seeking behaviour which is important for the success of any programme. Empowering a woman financially helps her in making decisions and by involving males in the communication process, one is able to create new avenues of support for all endeavours, not just related to earning a living but also related to health. Seeing the enthusiasm of the volunteers working with pride to bring about change in the health of their women and children for a minimal monetary gain has rekindled the lamp in my heart to go back and do something for my people back home. What Mamta started was akin to burning a torch to show the way, and the women of the community started lighting each others homes by enlightening other women on the importance of institutional or safe delivery and immunizations, thereby preventing them from death and disease, and enabling improved care for their children. (22 September 2009)

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NATAK BHAARVA AAVO VAAT MAJHANI LAVYACHHE!

Come watch our play we have interesting things to say! Taking the creative route to health literacy Health literacy outreach activities in villages of Chhota Udaipur Block (Vadodara District) in Gujarat led Shivani Mathur to share a series of vivid images as she traveled, lived and broke bread with a troupe of actors from Darpana for Development. The purpose of this field visit was to present a natak (theatrical performance) mirroring attitudes, behaviours and practices of village communities in relation to health in order to create a platform for open sharing for a communication needs assessment and participatory research.

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Giggles and shy smiles erupt among the women as a focus group discussion touches upon issues related to womens personal hygiene, including genital health and menstruation. Curious men enter the village courtyard as children await the start of a performance or natak on the importance of healthy behaviours. The facilitator, who is also trained as an actor, was just like the other women- from the same region and rattling questions in the local Rathwa language. Chowkdi village came alive on this sleepy afternoon with the laughter of men, women and children who were kept guessing on the full import of this interaction. Their participation and knowledge-gain was evaluated two weeks later and showed a significant rise in understanding of health issues.

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Inside one of the actors homes, his mother prepares traditional rotla (Indian bread from maize) and dal (pulses) for the entire troupe of actors on a choolha (earthen stove). Plucking corn cobs from the tiny back yard and passing the rotla around, reminded me that one does not need to have a lot, to share and be hospitable. I was welcomed into their home and hearth, as we sat on plastic sheets and devoured many meals with laughter and tears, both from the smoke and the chillies. The only female actor in the troupe invited me for a meal with her family on my next visit as her present home did not have a roof to shield us from the rain. Needless to say, Im waiting.

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A mid-day stroll around the weekly village haat on Sunday. The faces, shapes, colours and contours stand out and yet, blend in with much fanfare as a kaleidoscope of economical and unique wares are marketed and sold. From farm implements to soda and bows and arrows to clothing the haat is known for its diversity and rikshaws full of people arrived to throng its lanes. I was surprised to learn that bows and arrows were used as much for hunting wild animals as for davo bhango or a marriage settlement in case a couple eloped and family honour required to be asserted. Songs in the Rathwa language about village life screamed above the din, as I was warned against purchasing food items for fear of adulteration. I left with a very large funnel, delicate hand-woven cloth and some coconut water.

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Our first visit to the Nanidumali village was at 3 pm, but as the day was overcast most of the village folk were engaged in the fields and performance led participatory research would not have been possible with a sizeable audience. The original plan was to return to Ahmedabad that night, but the troupe decided to stay on, so we climbed the Tejgarh mountain instead. After singing and dancing atop large rocks, it poured as we descended- slipping and ripping through foliage, wading through waistdeep ditches to make our way back to the village by 5 pm. Rain played spoilsport to our outdoor performance and the electricity supply too, was interrupted. The troupes ingenuity had been put to the test. They walked through the village, playing the dholak (percussion instrument) and sang in the rain, sans mike or loudspeaker to lead people into a large cow shed. The headlights of our car and kerosene lamps across the shed bathed the actors in light adding further drama to an already gripping perfrmance.

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First drought and then the rain. A persistent drizzle made us seek shelter in Mukesh bhais home, a veteran host to the troupe through the local NGO network at Bhilpur village. The damaged maize crop lies salvaged from sudden rains and stored inside his shed, where one of the performances was held. Inquisitive villagers reached the shed as the announcements on the loudspeaker grew louder and the crowds started to move inside. Seen here, some tried to catch a glimpse of the action by perching themselves upon the windows.

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A view of the Tejgarh hill (on the left) as we drove past emaciated cattle and beautiful, meadows strewn with pebbles. It was the first time I had been to a place where the massive Indian Railways network was yet to reach, with tracks still being laid at several hours distance. We climbed up, past thorny shrubbery and slipping on large grey boulders in the hope of walking through historic cave art, but once we were up there, the adventure and the view took our breath away. It was another matter that we had climbed the wrong side of the hill and going around it, at that height and level of difficulty was impossible!

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A performance in Malu village culminates with the actors singing a song on healthy behaviours, emphasizing the need for families to take care of their health to enjoy a happier and longer life. In the interaction that followed, a local accused the troupe of turning the women of the village against the men, as one vignette of the play showcased health through the gender lens; expanding on the common perception that being a women was a curse as it entailed health problems, pregnancy, complications and aches and pains on account of heavy work, in a sensitive, but comic manner. The discussion was taken forward by members of the troupe, as they expressed our intent of merely sensitizing the audience to the plight of their family and community members, to which none were in disagreement. Open and transparent community interactions are obviously a powerful, although challenging, tool for progress.

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The audience enjoys a light moment. The scene being enacted was of a school-going child who pleads with his mother to give him some money to eat only deep-fried foods outside the home, causing indigestion and illness. In the discussions that followed, several men and women made references to what they had just observed as they shared information about their dietary patterns and traditional recipes. In addition, issues regarding water purity, food hygiene and malaria prevention also came up.

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The actors, in traditional costumes, sang traditional numbers and danced the Timli (a folk dance from the region) to attract crowds. Some of these songs capture the aspirations of the audience as they were about courting a jeans-clad city girl, longing for ones love while at work and sources of entertainment around the village. The actors were selected from district-wide auditions and they provided insights and critique in the process of creating the performance. Their lives are as complex as those of the village folk in the audience, with some of them finding work in the removal of dead carcasses, tanning, working in the fields and even laying some of the bridges we traversed.

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A stack of about 60 commodes lying outside a shed in Bhilpur village, awaiting installation since several months. Community interactions revealed that the entire village population of two thousand odd people has access to only one shared toilet where they may relieve themselves, if not in the open. The water they consume is from a twelve-year old rusting handpump.

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MAKING A DIFFERENCE
REACHING FAR: HIV AND AIDS CARE AND SUPPORT IN REMOTE VILLAGES
By Usha Rai Four years ago, Ramoji (name changed), a young, 16-year old boy from Guntur in Andhra Pradesh, when he was just 16 , was thrown out of his home by his parents when they got to know of his HIV status. Infected after a blood transfusion Ramoji was in Class 11 and extremely keen to finish his schooling, but his life started to take some sharp turns after the family rejected him. The Voluntary Counselling and Testing Centre, fearing the worst for the dejected young boy, that he may commit suicide, referred him to the Guntur District Level Network of People Living with HIV and AIDS (DLN). The DLNs, which are playing a great role in providing hope and succour to those infected, assured him he could lead a normal life like others but he would have to be on medicines. When his parents refused to take him back despite the DLNs efforts, it moved him to the hostel of a religious institute where he could concentrate on his studies. Here again, the religious head misled Ramoji and forced him to give up the medication. He fell ill again and this time his CD-4 count dropped to an unbelievable low of 5. The DLN then moved him into a care and treatment centre for 45 days and ensured that he did not default on his medicines. After he recovered he was made economically independent as an outreach worker of the DLN. He could stay in a working peoples hostel, do his work as well as study. Now 20 years old, Ramoji has completed his class 12 and has enrolled for graduation through distance learning. Great strides have been made in the care and treatment of people living with HIV and AIDS (PLHIV) and at the core of the transformation taking place in their lives are the people themselves. It is with great courage that they have come forward to acknowledge their status and advocate for those not so brave to speak up or try to access critical anti-retroviral treatment (ART). The District Level Networks of positive people have spread deep into the interiors of India locating others like themselves and bringing them to Centres for support services. While this has helped tremendously with de-stigmatizing the infection, even more heartening is the fact that today, close to 300,000 PLHIVs are accessing care and medication. The second line of ART too is available, though not all people are able to access it, says Senthil, Vice President of the Indian Network of Positive People (INP+). He was in Delhi with 350 positive people from across the country in December 2009 for a national consultation organized by the Population Foundation of India and its partners who provide treatment and support services in six high prevalence and eight vulnerable states through the Global Fund for AIDS, Tuberculosis and Malaria (GFATM). In fact, Mr. Taufiqur Rahman, regional leader of the GFATM, announced extension of the support to India for the next six years, starting March 2010.

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Senthil said some 283 DLNs had been established in 27 states. These networks follow up on all issues whether it is availability of ART, tackling stigma and discrimination or a close monitoring of those on medicines. Ensuring minimal default rates on the drug regimen is a vital contribution to the overall response to contain HIV and AIDS. That is why it is heartening to know that the network has plans to expand to 220 districts by 2012, and then by 2015 to be positioned across India to spread maximum benefit from its advocacy and service delivery mechanism. Support group meetings are held thrice a month by the DLNs and there is a sharing of views, challenges and successes of positive people. The champions of the DLNs are the peer educators, all of them volunteers. They are members of the community who have been selected and trained for their leadership qualities, their standing in the community and their communication skills. There are some 13,500 peer educators in the country and each of them is responsible for 10 PLHIV. It is they who are responsible for bringing back into the fold defaulters or those who have stopped treatment. Saroja Puthran of INP + says the DLNs provide home-based care, psychosocial support, referral services and linkages with government, NGOs, CBOs, need-based advocacy and legal support. They offer individual as well family counseling and also volunteer to undertake field/home/hospital visits. There are 196 Service Delivery Points in the network, according to Senthil, and the registration of positive people, particularly in the high prevalence states of Andhra Pradesh, Tamil Nadu, Karnataka and Maharashtra-- has been so thorough that it is easy to identify and track down regimen defaulters. Around 5,457 PLHIV who had been listed as defaulters between 2007 and 2009 have been persuaded to come back for treatment. In Manipur and Nagaland, the other two high prevalence states of the countrydistances and difficult terrain have made registration as well as management of defaulters more difficult. Who are these dropouts? Many of them are those who have not informed their families about their HIV status and are scared of being seen at an ART Centre. In fact, it is easier to trace defaulters in a village, where everyone knows everyone else, than in a city, says Senthil. That is how deep and strong the arms of the network are! Hanglem Bimola, 40, a widow on ART, now works with the NGO Meetei Leimarol Sinnai Sang (MLSS) at Imphal, Manipur, as a peer educator. A graduate from the Bishnupur District of Manipur, Bimola married an injecting drug user in Imphal in 1996, not knowing his HIV status and had a baby girl the following year. When she was pregnant again, her husband died. The child born in 1999 died after three months. The discrimination by her in-laws began. They would not eat food cooked by her and she had to stay in a separate room. She went to her parents house and in 2001 fell ill and was diagnosed HIV positive. She tried to support herself and her child by selling vegetables but no one would buy her vegetables because of her HIV status. So she moved to Imphal. Bimola recalls that after she bathed in a public pond at Utlou village, people of the village held a public meeting and disinfected the pond because they feared the water was contaminated. Then she got in touch with the NGO MLSS and soon graduated to becoming a peer educator. Now she works with the Bishnupur Network of Positive People in an Access to Care and Treatment project. Not only has she been able to rehabilitate herself but is among the network of positive people providing hope and succour to those infected. Mr Taufiqur Rahman of the GFATM said with political commitment, a good delivery system and the integration of NGOs, positive peoples networks and the involvement of the corporate sector, India had

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been able to achieve its targets of containing the infection well in advance. Globally the incidence of HIV and AIDS is coming down and India too could hope to see a reversal of the infection in the next five to six years, says Rahman. Usha Rai is a senior journalist who writes on development issues and lives in New Delhi.

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RESOURCES Focusing Resources on Effective School Health (FRESH) Framework

Improving the health and learning of school children through school-based health and nutrition programmes is an essential component of the health promoting schools initiative of the World Health Organization (WHO) and of global efforts by the United Nations Childrens Fund (UNICEF), United Nations Educational, Scientific and Cultural Organization (UNESCO) and the World Bank. Their aim: to make schools effective as well as healthy, hygienic and safe. Overall, this inter-agency action is perceived as Focusing Resources on Effective School Health, and giving a FRESH start to improving the quality and equity of education. URL: http://www.freshschools.org

Theatre-Based Techniques for Youth Peer Education: A Training Manual (2006)

At This training manual provides an overview of using theatre in health education. It contains four peer theatre training workshops, a series of theatre games and exercises that can be used in trainings, and information on developing and building a peer theatre programme. This tool was produced for the Youth Peer Education Network (Y-PEER), a project by the United Nations Population Fund (UNFPA) and Family Health International (FHI). URL: http://www.fhi.org/en/Youth/YouthNet/Publications/peeredtoolkit/TheaterTraining.htm

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3FOUR50.COM

An awareness-raising and action-based online social networking website has been started by the Oxford Health Alliance as part of a campaign that seeks to raise awareness and promote action on chronic disease prevention. The name represents the Oxford Health Alliance's key message: 3 risk factors tobacco use, poor diet and lack of physical activity contribute to four chronic diseases: heart disease, type 2 diabetes, lung disease and some cancers, which, in turn, contribute to more than 50 percent of deaths in the world. The website is a useful compilation of information and stories which tell the many tales of fighting and living with chronic diseases and also marks the launch of a Global Audit on Chronic Diseases that seeks to change both hearts and minds, and pockets to fight the pandemic of chronic diseases. 3FOUR50 aims at facilitating partnerships, collaboration and action among experts, leaders and innovators from a variety of sectors, and people genuinely concerned with chronic disease prevention. It will also allow new audiences, such as young people, to become engaged in the debate and work towards common solutions. URL: http://www.3four50.com/

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Injecting Drug Use and HIV/AIDS in India An Emerging Concern

The The incidence and extent of injecting drug use has been a subject of debate. Against this background, this monograph is a timely initiative towards consolidating information on injecting drug use which has emerged from separate components of the National Survey on Extent, Pattern, and Trends of Drug Abuse in India. This monograph, published by United Nations Office for Drugs and Crime (UNODC, Regional Office for South Asia) is available online and describes the nature and extent of injecting drug use in India and its negative consequences for health, including transmission of HIV and other blood borne infections, and provides direction for recommended interventions. This document provides useful information for policy planners and implementing agencies and may assist in developing appropriate strategies to address this aspect of drug abuse that poses a real threat to the health of our population because of its direct linkage with the spread of HIV/AIDS. URL: http://www.unodc.org/india/idu_and_HIVAIDS_in_India-Monograph.html

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Disclaimer: This news letter is made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this document are the sole responsibility of Public Health Foundation of India and do not necessarily reflect the views of USAID or the United States Government.

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