Games with Goats

I’m writing this in retrospect, as time seems to have vanished at breakneck speed the last few weeks as it always seems to just when you need more of it.

The Sri Ram Nagar project continues to progress well, and I'm starting to realise I'm going to leave just as the momentum really gets going, but perhaps that's exactly the way it should be. I am hoping that this is just the very beginning of a long lasting participatory health education programme, with the community health workers facilitating the group as the young people involved become more able to explore and share health education with each other and the wider community

In the first couple of weeks we lost a couple of girls due to unforseen work commitments but thankfully gained a couple more, Sita and Preethi, plus we finally recruited our first boy, Deepak, who has become invaluable as our chief artist and design manager and unbeatable champion of ‘Bakree’, the game we have been working on as part of TB health education. At this point I must correct myself from the last blog entry. I already mentioned that my understanding of what is happening when everyone speaks in Hindi is somewhat limited at best, but I(apparantly optimistically) thought I had a fair idea of what was going on when the medium was English, it being the language I speak and all.

When they first told me about their idea for the TB education game I was fairly convinced that the girls were saying it involved ‘Gods’
Highly impressed, I had visions of elaborate paintings of Ganesh and Hanuman giving out positive health message. I started to wonder when these Gods were going to appear at about the same time that I started wondering why everyone kept talking about bakree (Hindi for goats). It transpired that the girls were saying ‘Goats’ not Gods and that the game is more about the big goat eating the small goats to get to the other side of the board than it is about Hindu deities! I like goats too though and since a few of them sit in on our meetings it seems rather appropriate that the game should involve them.

A couple of weeks ago I realized the personal implications that this project has on the people involved, when I discovered that one of the girls Roopa (name changed to protect identity) lives with the social stigma of having several family members be infected with TB. Unfortunately her father has never managed to complete the grueling 8 month course of medication required to treat the illness, leading to infection with Multi Drug Resistant TB, which is much more difficult to treat, and reinfection of family members. To begin with Roopa was shy and didn’t seem to keen to participate. She hung back on the outside of the group, listening intently but not really getting involved. I was aware of the other girls giving her sideways glances and gauging her reaction as we opened discussion about TB in the first couple of meetings. Living in overcrowded living conditions is one of the major risk factors for the transmission of TB, and it is easy to see how the disease spreads from home to home. It is also easy to see how word spreads and why people are so fearful of being diagnosed with TB because of the impact it may have on their social life and peer perception.

Watching Roopa get more involved every week, moving closer into the circle and beginning to voice her opinion more confidently has been a joy. Although at 19 she is the oldest of the girls, her reading and writing skills are far behind the others yet she has persevered with grace, and determination. One of the younger girls immediately went to her side and helped her out in those first meetings, without making a fuss, or drawing attention to the fact that she was struggling to keep up with the others. Last week I watched her giggling with one of the other girls, scolding her when she made a mistake and carefully writing her piece on the art project she was doing and it really struck home to me that this type of participatory approach does not only benefit physical health in a community. It strengthens so many aspects of learning and confidence building, skills that hopefully will go on to last a lifetime.

After our first meeting, and our second first meeting due to changing faces, we steamed ahead with TB health education. Masarrat and Nasir used some really good interactive models to demonstrate the pathophysiology of TB and used role play to demonstrate the importance of completing treatment and taking medication every day.

We also left a few books for the girls to read and over the course of a few meetings, compiled a list of positive and negative statements about TB that the goat game would be based around. The girls clearly study hard between meetings because they have been spouting some great information about TB health promotion, and it is obvious they are engaged in the subject. Some girls have started sharing stories they have heard about people with TB, and we have a growing group of grandmothers sitting on the sidelines, who appear to be paying attention to what we are saying, in between looking after children, collecting water and gossiping about the neighbours. The plan is that once finished the game will be played in the courtyard, to consolidate the knowledge the group has gathered and to start to raise awareness in the community about TB, before we move onto the next phase of the project where we will carry out a small community study on TB symptoms and awareness.

We have also been continuing with our English lessons although they are not going exactly to plan (I take my hat off to all English teachers, and curse the Scottish education system for not teaching us English grammar). Last week we drew a chalk body on the ground and labelled it in Hindi and English. Well that was the idea, but the Hindi quickly got dropped and the class dissolved into hilarity over my confident announcement that the Hindi word for toes was ‘ungli ka pairs'(translates as the feet of the fingers). It transpired the next week that the girls had remembered none of the English body parts we had learned and so we stepped it down a little, playing ‘heads shoulders knees and toes’ until they could remember the words. I’ve been testing them since, and the song seems to have worked!

We are now frantically trying to complete the construction of the goat game, which needs to be done faster than intended thanks to the announcement that 6 of the girls will be leaving for summer holidays. Until the end of July. With my British plans waylaid I was sure that would be the end of the project and we would call it a day after the goat game was played. However Masarrat is clearly made of stronger stuff than I am and, after looking at me like I was crazy when I seemed a tiny bit stressed out that 75 percent of our group are disappearing, stated that we would continue as before, with the people we have left. Hurray for the Indian ability to roll with the punches !!

Getting Started-Trials, Tribulations and Triumphs

The fact that I am setting up this blog 6 weeks before I leave Bhopal is testament to the fact that nothing ever goes the way you think it will.
I arrived in December armed with some good books about community health,a Diploma in tropical Nursing from the LSHTM and a vague idea that I wanted to work with the community health workers in the bastis surrounding the Union Carbide Factory. Surely enough to do something brilliant with, thought my arrogant Western head.

Of course this is India, and, as I should have learned some years ago,timescale takes on a whole new dimension. My idea that productive meetings with the community health workers,bullet pointed action plans and enthused motivated responses leading to a champion project being successfully born my first week there ?

Eh. . .no

I will be honest; as the weeks rolled by in a haze of failures to communicate, cancelled meetings, we ll do it tomorrows and a general lack, or so I perceived, of interest nothing appeared to materialise. The frustrations, anxiety and feelings of failure of trying to be accepted by a well established team of Community Health Workers, who lets face it didn't have to the time or the inclination to listen to a weird Scottish volunteer try to put her point across in pretty rubbish Hindi. I made the classic mistake of expecting too much too soon and in my excitement forgot that the development of ideas can only come from building relationships, sharing skills and ideas and allowing time for trust and respect to be earned. In the process of this came a whole range of emotions; a definite feeling of one step forward ten steps back, learning to laugh at myself as everyone else laughed at me (easier when you actually get the joke let me tell you) and an eventual acceptance that maybe my role here was going to be something completely different to what I expected. And so I gave up on the idea of a participatory child centred health promotion project and focused on what the Community Health Workers really wanted to learn. How to take blood, give IV drugs and do clinical examinations.

The psychological and emotional impact of being in Bhopal, the frustration I felt with my self, and a general lack of contact with the outside world started to take its toll. After endlessly pondering my frustrations with Tori and Michael, a wonderful Australian couple who kept me sane here in Bhopal, and who scooped me up some time later in Calcutta to ply me with red wine and beer, I legged it to the Andaman Islands to gain some perspective. I decided I wasn't going to stress about anything any more and would take each day as it came. If the project I had in mind didn't come to fruition then so be it. And as always the minute I stopped fretting the wheels started to turn. Unbeknown to me some books I had ordered arrived in my absence, and on my return I was eagerly approached by Masarrat, one of the Community health workers. "We've had an idea. We want to do a child based heath promotion project in the basti. Can you help us?" Ummmmmm. . . sure. And so the story begins.

Masarrat and Nasir had identified some community conflict that was having an adverse effect on the maintenance of the community garden in Sri Ram Nagar and though it would be a good idea to create a bond between the children of these families, encouraging them to work together and build relationships. An ideal situation to form a group of young people. Our first meeting was at the beginning of April with 8 girls from the basti of Sri Ram Nagar. Aarti, Jyoti, Dolly 1, Dolly 2, Asha, Mala, Pooja and Vasha, all aged between 14 and 18. The meetings take place on the doorstep of one of the community health volunteers homes. The sociable setting means men, women, children, goats and dogs are continually dropping in to check out what is going on, which can only be good for community spirit.

The idea of participatory health projects is that children identify issues within their community through research and health education and then plan an intervention to address the issues they have identified. This empowers children, gives them confidence and allows them to disseminate useful health information to peers and other members of the community to create healthier, more positive environments. It was obvious this concept of learning was new to the girls, as they sat in a solemn line in front of us and waited to be told what to do, indicative of the tell and repeat system of education throughout the country. However they soon warmed up and came up with some brilliant ideas. They wanted to create a file with information about medicinal pants used in the community garden, that everyone can access, and they decided that they would like to do an art/music and dance project on a health issue in the community.

Masarrat suggested they might like to investigate TB and together we started to devise a plan. It was interesting to listen to the girls fears: Being dismissed or ridiculed by the community because of their age and perceived lack of knowledge seemed to be the biggest concern which we alleviated by explaining we would all learn together about TB before any community involvement occurred. We also reminded them that they have the full support of the community health volunteers, and the community health workers, who would happily support them if necessary, and that their opinions knowledge and ideas are valid and worthwhile.

The girls expressed a desire to improve their English and so we came up with a plan to spend half an hour at the end of each meeting having an English class. For fun we will each learn 3 new words in English (and for me Hindi) and tell them to each other at the start of every meeting, together with a short definition. The one great thing about the language barrier is that it creates great hilarity (usually at my expense)and a more familiar environment where we meet on our common lack of understanding.

It's early days but I'm really excited about the potential for this project. If the girls enjoy it and want to continue they can hopefully create a regular young person based health promotion group, identifying issues that affect their communities and addressing them in fun and interactive ways. In the mean time I am trying to get a handle on English grammar, and Masarrat, Nasirbhai and I are putting together some health education information about TB that we can share with the girls at our next meeting. Its a learning experience for all of us. For me, learning that starting small is a positive thing and that if you remember to stand back and let things blossom on their own, they might look different to how you first envisioned it, but that is almost always a good thing. Lets see what happens.