“When I go to meet future mothers, I try to explain to them that a ‘tikka’ or injection is important as it saves us from dangerous diseases, especially our children,” says Santoshi Gandharv, a senior village health worker from Semaria, a village in Bilaspur district, Chhattisgarh.
“Women who stay and give birth in the jungle are at high risk of infection, as seeking treatment is compromised due to long distances and other obstacles.”
– Rajkumari Oraon, maternal and child health worker
“Many of them don’t know that getting their newborns vaccinated – especially against diseases like tuberculosis or polio – can save their lives, so I make sure they understand.”
Gandharv’s work here, where health indices are below the national average, is vital.
Vulnerability in figures
Chhattisgarh, a large state in central India, has a majority population Adivasis or “tribal” population, a generic term in India for indigenous groups who are often socially and economically disadvantaged. According to the National Family Health Survey (NFHS-5) for the period 2019-2021, more than 77% of the population of Chhattisgarh is rural.
While the under-five mortality rate across India in 2019-21 stood at 41.9 per 1,000 live births, in Chhattisgarh it was higher: here, 50.4 children in 1,000 died before their fifth birthday. Across India, 18.1% of women were underweight; in Chhattisgarh, this figure stood at 23.1%. And then, women in Chhattisgarh received less help during their pregnancy: 65% of women in Chhattisgarh who were pregnant during the five years of the survey reported having had a prenatal check-up during their first trimester . The India-wide equivalent figure was 70%.
Gandharv and others like her are a vital link in a vulnerable health care chain. Known to colleagues and patients as Santoshi Have I got, meaning “elder sister,” Gandharv has been a community health worker for 23 years. She is employed by a health NGO called Jan Swasthya Sahyog (JSS), but her work is comparable to the role played in other communities in the state by accredited social health activists or ASHA workers employed by the government.
“Almost invisible”
Here in Bilaspur district, JSS runs an intensive community health program covering 72 forest and forest fringe villages, home to a population of 40,000.
Minal Madankar, a public health professional working as the maternal and child health program coordinator with the JSS, says most people in these villages come from tribal communities or other groups designated as particularly marginalized.
“Most of the people are from the Gond tribe, followed by the Oraon and Baigas tribes. (These are) known as Particularly Vulnerable Tribal Groups (PVTG), who live in the interior forest villages.
“Before the JSS, the health system was almost invisible in this area,” explains Madankar. “The communities were very shy and vulnerable in every sense of the word. Over the years, we tried to recreate a strong health and healthcare system in these villages with village health workers (CHWs) supported by our referral hospital in Ganiyari.”
Choose trust
JSS has 146 ASVs, she explains, each elected by the community to serve them. “Confidence is the main component of becoming a village health worker,” says Madankar. “The village comes together and votes on who they think is best, not on the basis of qualifications, but on the basis of the relationships of women in the community. We then train women to watch out for minor ailments like colds and coughs or fevers, but also how to recognize chronic illnesses like tuberculosis, hypertension and diabetes during their regular rounds in the villages.
Since the village health worker is connected to the community, he knows which couples have gotten married and begins visiting these households to find out if the women need support or if they have missed their periods. If a woman is found to be pregnant, she is registered at the antenatal care clinics run by the JSS.
Rajkumari Oraon, a maternal and child health worker, says: “Women who stay and give birth in the jungle are at high risk of infection, as seeking treatment is compromised due to long distances and other obstacles . We make sure the woman knows about all the vaccines they need, including tetanus, and of course vaccines for their newborns like BCG, polio and hepatitis B.”
From the jungle to the urban skyscraper
Puja*, a midwife in private practice in Bengaluru, an urban metropolis in the relatively wealthy southern state of Karnataka, now works with mostly affluent women, but before that she worked for a month with JSS in Chhattisgarh. “The urban-rural divide really hit me when I worked with JSS for a month. Nutrition was the biggest difference I saw. Women in Bangalore have access to a wide variety of food and in the tribal areas (of Chhattisgarh). Although it seems counterintuitive, they did not eat as many fruits and vegetables.”
When she is in Bangalore, she regularly devotes a large part of one of her second trimester visits to the topic of vaccination. She explains why she considers routine injections to be an even more essential intervention in more disadvantaged contexts. “The health of the mother has a direct impact on the health of her unborn baby in utero. If the mother – in childhood and throughout her adult life – has suffered from malnutrition or undernourishment, the health of the baby is affected. Access to vaccines for both mother (during pregnancy) and baby (after birth) can save lives, especially when there are chronic deficiencies in a community. Vaccines can strengthen the body’s ability to develop immunity and fight infections, which may not be fatal if the child is well-nourished, but can have a debilitating impact on a child who does not have access to adequate nutritious foods.”
There are other disparities. “Access to health care is of course also an important factor, but even more so, it is access to information that is important.”
“Access to health care is of course also an important factor, but even more so, it is access to information that is important.”
– Puja*, midwife in private practice in Bangalore
Most of her clients in Bangalore have a higher level of what she calls “mainstream education” than the women she met in Bilaspur district. She clarifies that she does not reject the knowledge that circulates in the tribal areas: “In Chhattisgarh, there is generational wisdom,” she says. But in both contexts, she insists, access to quality, clear and understandable information is vital.
“I practice what is called ‘informed decision making’, which means my role as a midwife is to give parents all the relevant information and help them make the decisions they need to make .” To explain vaccination, for example, she uses lots of visual aids and diagrams to overcome any potential language barriers. “There is a lot of misinformation and often parents do their own research and ask questions.”
In Bangalore, as in the village of Chhattisgarh, a bond of trust maintained between mothers and health workers is essential. “The best thing I have found to do is to focus entirely on the mother,” reflects Puja. “It’s all about the relationship we develop with the mother and the family, and when we’re talking about something as confusing as vaccines, medications, nutrition, it can be overwhelming. Patience is key. .”
Huge disparity
The JSS has made great strides in tackling communicable diseases and malnutrition in Bilaspur district, Puja says, “but the disparity (between rural Chhattisgarh and urban India) is still huge.”
Dr. Nafis Faizi, an assistant professor and epidemiologist at Aligarh Muslim University who specializes in community medicines and health systems, says the disparity is deep-rooted.
“Health care has always been better in Karnataka. Differences in health systems and trust in health services differ significantly between Karnataka and Chhattisgarh. Apart from this, social differences in terms of economic status, literacy, participation and health system accountability also exist. This is also clearly reflected in the NFHS-5 data. Deprivation and discrimination mired in intersectional challenges in access and affordability are well more (prevalent) in Chhattisgarh than in Bengaluru.
“In Bilaspur only 46.9% of mothers had the recommended four antenatal care visits, compared to 81.8% in Rural Bangalore“, he continues. “When we compare vaccinations, only 52.5% of children in Bilaspur are fully vaccinated, compared to over 90% in Bangalore.”
The fact that a child is much more likely to survive beyond five years in Bangalore than in Chhattisgarh is influenced by women’s health and further complicated by nutritional deficiencies and inadequate social benefits. “The gaps become more pronounced with each deprivation,” he explains.
“We also often miss out on women’s health. Many programs are guilty of focusing only on reproductive health, thereby reducing the overall importance of women’s health.”
* Name changed
