ON THE CASE

Child Advocates for Social Empowerment

Photo exhibit by Marilyn Smith

Veena (29 years) and her sons are third- and fourth-generation residents of Janta Colony – a community of 14,000 people that butts against the limits Chandigarh, the capital of Punjab and India’s most modern city. But you won’t find Janta Colony on any state or city map, an oversight that allows all levels of government to consider it a temporary slum or bustee in local slang.

Situated on India’s northern plains, the bustee is hot and dry much of the year; temperatures can soar to 45°C or more in the summer. Even in late November, just before the winter cold sets in, it is warm enough at 9:00 am to enjoy being on an open rooftop. Veena joins 15 other bustee residents for 20 minutes of yoga. It is a time to put some distance between their daily lives and their roles as agents of change.

Over the past six years, Developing Indigenous Resources (DIR)* has given this team of Health Promoters (HPs) daily training in health fundamentals, including a strong focus on nutrition and disease prevention. DIR believes that three inexpensive pieces of equipment -- bathroom scales, stethoscopes and blood pressure gauges -- can be powerful tools to monitor the general health of residents, and the need for further intervention.

Each HP is responsible for 200 households in Janta Colony. One of their main jobs is to track, on a monthly basis, the weight of every child under the age of five years. These visits create a natural opportunity to share knowledge on many health-related topics.

As in most slums, general poverty makes malnutrition a primary concern; but high rents in Janta Colony contribute to a higher incidence of severe cases. Champa (22), together with her second baby (2 months), barely pushes the needle on the scale to 34 kg.

For DIR, monitoring child health begins at the earliest possible moment. HPs visit pregnant mothers every month to monitor weight, blood pressure and foetal heartbeat. Often, their visits are a kind of “community health” as friends and neighbours listen in.

The effects of early mal nutrition can be life-long. Chandigarh doctors attribute Prem’s blindness, at least in part, to his mother’s severely malnourished condition during pregnancy. In addition, he was born at home in a remote village with no immediate access to medical care.

DIR HPs are recognised for more than their blue jackets. Bustee residents such as Rangeelie, particularly those with little or no education, have come to view the HPs as local experts and welcome their arrival.

As most homes in Janta Colony have only one or two rooms, much of daily life transpires outdoors and even young children are exposed to the elements.

By mid-day, a self-inflicted blast of cold water on the front porch can be sheer delight, but most homes lack running water so having a bath starts with hauling a bucket.

But water is a serious problem in the bustee. Poor maintenance of limited drainage systems leads to back-up of waste water. Within steps of every doorway, non-biodegradable matter floats atop fermenting organic waste while a variety of insects, including malaria-bearing mosquitoes, skim the surface.

Traversing the bustee invariably means passing within inches of wide expanses of open swamps or equally contaminated creeks (nullahs) that flow between rows of tightly packed houses.

The most prevalent risk for bustee children is contracting diarrheal diseases from poor hygiene, contaminated food or dirty water. For infants and toddlers, severe dehydration can spiral downward to death in a matter of hours. DIR makes it a priority to teach every woman how to prepare an oral re-hydration solution from basic kitchen ingredients: boiled water, salt, sugar and a pinch of baking soda. A pinch of lemon or lime helps mask the remedy's terrible taste.

As HPs got to know the families in their sectors, they realised that many women work long hours cleaning houses or selling goods in the streets of Chandigarh. It often falls to the eldest child to carry out household chores and take care of their younger brothers and sisters.

Sometimes, as in the case of Madhu, the child left in charge may be no more than seven or eight years of age.

When DIR recognised the responsibility older kids carry, it began an after-school programme for those aged 9 to 13 years. Child Advocates for Social Empowerment (CASE) uses fun and games to teach basic health and hygiene. Participants like Ruby are encouraged to share their new knowledge with their parents and siblings.

A most subtle aim of CASE is to promote the social and physical development of these pre-teens by making sure they have a chance to have fun – away from the family responsibilities.

HPs devote late afternoons, the most likely time to find women at home, to giving courtyard cooking classes. Menus are carefully prepared by DIR’s nutritionist to derive optimal benefit from locally available fresh produce and to keep prices at less than two rupees per person (CDN 0.05 or EUR 0.02).

Vaishakha’s birthday party was a sign of success. The menu included cake and snacks, but also a well-balanced meal of rice, dal and vegetables. Her mother and aunts used to believe that “expensive” food equalled healthy food. Following HP advice, they’ve stopped buying processed foods and watched their collection of eight children move from the “Red” to “Green” Zones on DIR health charts.

DIR statistics, confirmed by an independent assessment, show that the HP strategy is working. The incidence of severe malnutrition amongst children dropped from 87% in 2004 to 40% in 2010, and almost 100% of bustee women gave birth at the hospital – compared to the national average of only 41%.

HPs also remind mothers about upcoming immunisation clinics held in the bustee and assist government officials. As a result, immunisation rates are 85% to 93% (depending on the disease) compared to 55% to 78% nationally.

Despite these positive gains, deeper analysis showed that DIR's efforts were having the least impact on the neediest children. Monthly visits were not enough to make a difference for those who are "grossly underweight" – a condition that creates high risk for other health problems.

At the age of 3 years and 6 months, a healthy child should weigh 13 kg to 14 kg. Yashika weighs just 9.5 kg. A weak immune system likely played a role in her contracting tuberculosis from her mother Sangeeta, from whom she remains inseparable.

Jyoti is one of the most severe cases: at 16 months, she weighs only 5 kg, yet her stick-thin legs are too weak to stand on. Her pale hair, skin lesions and protruding ribs suggest the onset of protein energy malnutrition. Desperate for nourishment, her body is drawing on its own reserves of muscle and fat.

DIR turned to the CASE kids for help by launching an "adoption" contest. By agreeing to visit a needy child at least twice per week, Harnul and the others could "earn" the chance to win prizes. The HPs would use two indicators to measure progress: the growth chart of the child and the family's knowledge of what CASE kids have been taught.

During one of her visits, Ruby starts by showing Jyoti's mother how to mix the oral rehydration solution. Later, while helping bathe and dress Jyoti, Ruby lectures the mother about keeping the house cleaner and preparing more balanced meals.

To educate more members of the community, the CASE kids write and perform street theatre and puppetshows. Afternoon matinees draw large crowds of all ages.

As DIR began to achieve its health goals, it expanded its programmes to include education and economic development. The first target was creating an alternative to “schools” in the bustee, which are seriously lacking in facilities and equipment.

DIR’s “School with a Difference” prepares pre-schoolers to win scholarships at the best private schools in Chandigarh.

In reality, getting a scholarship is just the first challenge. The long trip into the city – either in the DIR van or by auto-richshaw – means bustee kids typically leave for school while their city-dwelling peers are still sound asleep. Frequent power cuts make it difficult to keep up with homework at night.

To empower bustee women, DIR has launched a programme to loan sewing machine machines and distribute donated fabric. Harnul and his sister help their mother stitch small purses or gift bags for wine bottles, which are then sold in retail outlets or to DIR supporters. The work provides extra income while also giving women the chance to work at home and spend more time with their families.

DIR still faces multiple challenges, some associated with culture and traditions. Indian society generally places higher value on boys, and girls learn from an early age that their primary role is to take care of male members of the family.

Often, what few resources a family has are unequally distributed. All three of these rambunctious brothers are slightly underweight for their ages; Prabhati, their sleeping sister, weighs only half of what she should.

Despite the croweded living conditions in the bustee, Yashika spends most of her time alone. Even though her tuberculosis is under control, other mothers refuse to let their children play with her.

At the end of the day, Veena and other HPs stop to visit their colleague Rani, (left) who stayed home to help her mother care for her sister Sarita (centre), who has been ill. They all agree that DIR has done more than give them a job they love: it has created a sense of family and community across the bustee.

The CASE contest succeeded on many levels. Bustee residents are demanding more street theatre and 31.6% of the GUW children gained at least 1 kg. For some, this represents a giant step toward reaching the Green Zone. According to CEO Dr. Frederick Shaw, this philosophy of empowering people to solve their own problems is the key to the DIR model. If DIR disappeared tomorrow, the skills and knowledge it has taught HPs and residents would remain intact – and easily passed on for many generations.


The photographer · Marilyn Smith is a Canadian journalist/photographer, currently living in Paris (France). She specialises in science and health reporting, and has a keen interest in development issues.

The exhibit sponsors · This exhibit is generously sponsored by the Centre for Indo-Canadian Studies, the BC Regional Innovation Chair and the Global Development Institute, all at the University of the Fraser Valley (Abbotsford, BC, Canada).

To organise an exhibition · Please contact: marilyn@marilynsmith.biz