Reading and seeing public health

Our friend Vyom recently visited the Rural Health Training Center (RHTC) in Najafgarh in Delhi as part of field visit in the first semester of his public health course. He shares some of his observations from the classroom and the field. Many thanks to him!

For a new student of public health, understanding the functioning of the health system on ground is crucial. It is an exciting exercise, where you relate what you learn in the classroom with what you find in the field. It helps us evaluate how theories and concepts of public health apply to the real world situation, and how the experiences, situations and practices on the ground in turn inform the discourses around health.

I observed some aspects of this relationship between theory and practice during the visit. For instance, our readings and discussions so far have taught us that government health institutions have important social goals and they serve as the backbone of public health measures in any country, due to their reach and inclusionary set-up. And therefore, despite the problems within them, their importance cannot be undermined.  The RHTC in Najafgarh exemplifies this.

Foundation Stone of RHTC, Najafgarh

Located at borders of Delhi and Haryana, RHTC Najafgarh was the first public health center of India. It was started with financial assistance from Rockefeller Foundation in 1937, and was taken over by Govt. Of India in 1942 and later turned into RHTC in 1960. The centre covers the population of over 1,60,000 and heads six sub-centres. Though it falls under the jurisdiction of Govt. of Delhi, which has entirely different structure of health service system, a PHC and sub-centres were the exceptions here. Apart from OPD, emergency and outreach services, the centre also has specialist care units. I spotted long lines of patients outside the ophthalmic, pediatrics and orthopedics wards. Specialist care in a PHC is a rare occurrence in India and that’s why one of doctors commented, “it’s a PHC but it’s more like a CHC”.


Patients waiting to see the specialist

Along with preventive and curative health services, this facility also provides training to nursing students from government and private colleges. This is significant, because although many tertiary level institutions such as district hospitals and medical colleges provide this combination of service delivery and teaching, doing this at the primary level enhances the quality of work at the primary health institutions, which are in fact the first contact points between the community and the healthy system.

The interface between the health system and community/patients became clearer when I began interacting with patients. My joy was doubled when I came across a group of women who were from my hometown Siwan and Chhapra. Rapport building techniques of social work were not required here, greeting them in bhojpuri and calling them chachi (aunt) worked quite well. After an informal introduction they told me about their experience of that day. For them taking out a day for their health needs was a luxury. They had to wake up at 5 in the morning, do all the household chores and reach  the centre by 9. They walked to the centre which took around half an hour, as they could not afford transportation. It took them the entire day, from registration to meeting the doctor and taking the medicine.

Patients queuing up to receive medicines

When I asked them about their illness, they said that they didn’t have any specific ailment but they constantly felt weakness, fatigue and joint and body pains. One of them reported that the doctors don’t even consider it as illness and ask them not to burden the PHC. That ‘unmeasurable’ health problems, such as pain, is a neglected area, especially in case of women, gets exemplified here.

A woman informed that she was advised to drink milk regularly, to which she smiled and said, “only if we could afford”. The connection between undernutrition and ill-health has been well established in public health but what is less investigated is the intra-household distribution of food: exactly how much are women and girls eating in a household. Food habits are culturally and socially defined and gender plays a significant role: women eat the least and last, they fast regularly and some food items are prohibited to them during menstruation, pregnancy, widowhood and other events. Add to this the gendered division of labour in the household where women do the most strenuous work for the longest hours. Not surprisingly then, despite the growth in economic assets for a large number of households, majority of women are still so under-nourished, thin, and anaemic in India.

Adjacent to PHC was the JJ slum where Harish, a vegetable vendor from Ballia (U.P) lived. Seeing the slum dwellings, I couldn’t help but be reminded of Engle’s essay on the living condition of working class England in the 19th Century that we had read in the class. While there was a lot of difference between Engle’s description and what I was seeing in front of me, mostly because the contexts were so different and centuries apart, the  denial of dignity to the residents and its dangerous consequences was common in both. Harish narrated that they had no option but to drink the water that sometimes got contaminated with sewage water. The sewage pipeline was broken and since it ran parallel to the pipeline that supplied water used for household purposes, it often contaminated the water used for drinking and cooking.

Hearing this, I was reminded of John Snow and his work, something that every public health student reads. Snow, using epidemiological techniques and data, investigated the cause of outbreak of Cholera in London in 1850s and found the connection between the contaminated water source and the outbreak. Owing to his pioneering work, administrative measures were taken towards ensuring better sewage systems and efficient water supply as a public health goal in London more than two centuries ago.

But JJ slum is not London, nor do we have a John Snow by our side. Worst of all, we lack the willingness to learn from the years of public health research and action. So, maybe it will take some outbreaks and deaths before we turn any attention to the health problems that the marginalized populations are forced to face!