SNEHA at #NoPlace4Hate

By Shamolie Oberoi

Society for Education, Nutrition and Health Action (SNEHA) was invited to attend #NoPlace4Hate, a panel discussion hosted by digital media portal Youth Ki Awaaz. I attended the event on behalf of the Empowerment, Health and Sexuality of Adolescents (EHSAS) team on 23rd September, 2017

It started off with a performance by feminist spoken word poet Harnidh Kaur – highlighting the kind of abuse especially women face online just for having an opinion, political or otherwise. Yet, she maintained her faith in the internet as an space of democracy and expression.

The panel discussion followed, moderated by Karanjeet Kaur, the Deputy Editor of Arre, a popular digital media website. The members of the panel included Gurmehar Kaur, a student who was trolled online for speaking about peace between India and Pakistan, equal rights activist Harish Iyer and actress Tannishtha Chatterjee, who recently was a part of the film “Angry Indian Goddesses.”

Each of the panelists shared their experiences of being trolled online, with Gurmehar in particular mentioning that she often feared that this online violence would manifest itself offline. Harish Iyer spoke of his unique social position, i.e. being a part of the “male” majority and queer minority, and how it impacts the way he is perceived in online spaces.

Tannishtha and Gurmehar also made the important distinction between disagreement and abuse, highlighting that while different opinions can and should exist, they should not cross over to personal attacks and threats to safety. All three also shared the ways in which they tackle online abuse and hate- ranging from sometimes engaging with the trolls, resorting to humour or simply blocking those who spew hate.

At the end of the event, 3 members of the audience also went up to talk about their experiences of online abuse – two women spoke about the specific gendered abuse they face- fat shaming, being called sluts and being threatened with rape. The male member of the audience who spoke up talked about how he was threatened online for expressing a negative opinion about a particular political figure. He also mentioned that the level of online abuse has increased over the last few years.

It was an interesting discussion to be a part of, but I do wonder if it helps to hold discussions on topics like these with a small, middle to upper class “curated” crowd!


EHSAS activities round-up

Our Adolescent Health and Sexuality Education program has a strong community focus and is implemented in three sites: Kalwa, Dharavi and Kandivali and targets beneficiaries from informal settlements aged between 10 and 19 years. The overall vision of the program is to impart gender-equitable values, health and sexuality education through a gender-transformative approach and to create youth change agents. Below is a round-up of the August EHSAS community engagement activities by Shamolie Oberoi.

Mental Health Awareness Campaign

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The EHSAS team, along with SNEHA’s Prevention of Violence against Women and Children (PVWC) team organized a mental health awareness campaign at Chatrapati Shivaji Hospital, Kalwa, upon request from the hospital authorities.

The SNEHA team conducted three street plays on mental health at three OPDs in the hospital. The street plays were performed by five of our young change agents who are active in creating awareness in their communities on issues affecting adolescent girls. These girls have been trained in theatre skills.

The girls performed confidently, clearly putting across the intended message. They portrayed the specific problems faced by adolescents, for e.g., anxiety about exam results, adding that such things are a part of life, and shouldn’t be the cause of mental health issues like anxiety, depression. However, the message was also given that anyone suffering from these must seek help, and there is no shame in doing so.

The Dean of the hospital joined in to watch the plays. She encouraged our girls to speak up about mental illnesses, and to communicate and provide assistance to those who are
suffering from such illnesses. She suggested the setting up of a newspaper library that can be accessed by adolescents in the resource centre set up by SNEHA in vulnerable communities in Kalwa.

We also played a special game of ludo, with questions related to myths about mental
illnesses along with 56 women. The myths were clarified and a discussion was held with
these women participants. The campaign thus went off successfully, and our change agents were excited about the opportunity to spread awareness about such an important issue, while also showcasing their theatre skills!

Campaigns during Ganpati season

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31 st August in Kalwa: Our team organized games and other activities as part of their Ganpati Campaign in Jai Bhim Nagar. The event was supported by Mandal volunteers. 36 boys and girls from the community participated in competitions which included essay writing and drawing. A play titled “Main Chalati Hoon”, which covered issues such as safety and mobility, was also enacted. Approximately 150 people from the community gathered around to watch the play, and many girls came forward to speak up about their rights.

While the play was on, a boy passed a comment about one of our girls. To this, the girl remarked on the mike, “If we are not safe in our community, how can we move further…nobody is interested in putting a stop to eve teasing”. Her comment was appreciated by all those present, and the Mandal members spoke to the boy in question. The campaign went off successfully and was enjoyed by all who were involved.

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28 th August in Dharavi: Our team held a street play and organized games and activities as part of our Ganpati Campaign. About a 100 children from the community participated in the event, along with around 15 Mandal coordinators, 12 staff members and 15 youth volunteers. The participants thoroughly enjoyed the games, which included 4 corners, puzzles, a GK quiz and a few one-minute games.

Our Associate Project Director, Neeta Karandikar, then spoke to the crowd about child
sexual abuse, and the difference between “good” and “bad” touches. Our Community
Organizer Hansraj Pawar sang a self-composed song on SNEHA’s work for the crowd.
At the end of the event, EHSAS’ youth group performed a moving and educational street
play on the issue of child sexual abuse, which was watched by the 100 children who
participated, as well as another 30-40 members of the community. The play sent the
message that sexual abuse happens to both girls and boys, and any child facing such abuse should speak about it to a trusted adult. Information about the Protection of Children from Sexual Offences Act, 2012, was also given to those present.

The event was a success, and the Ganpati mandal organizers felicitated SNEHA by
presenting us with a shawl and shrifal, as a token of appreciation for our efforts.

Workshops for Change-agents

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A two day workshop with 51 Change agents, organised by SNEHA and supported by UNFPA, was held at Thane on 18th and 19th August 2017. Aimed at building responsible citizenship through personal transformation, the workshop included sessions on legal rights, brainstorming on personal values, development perspective and leadership styles. The group of change agents comprised young girls who have been active in performing street plays and identification of cases of gender based violence and sexual abuse in their communities in informal settlements across different parts of Mumbai.

A churning of thoughts has begun among the young girls and they felt compelled to think about the interrelationship between social structures and individual rights that they are entitled to. Given below is a brief on the various sessions with key discussion points:

Citizenship and Legal Rights

On the first day, an excellent ice breaking session on knowing each other was followed by Rama Shyam, Program Director, SNEHA, setting the tone regarding the constitution of India, our rights and responsibilities as Indian citizens. She placed the Constitution vis-à-vis the history of India’s freedom and need for safeguarding rights of citizens in a socially diverse nation.

This was followed by an informative and interactive session by Advocate Ujwala Kadrekar where she covered the Preamble and the significance of Articles 14, 15, 19 and 21 in the context of equality before law, equal opportunities, freedom of expression and right to life with dignity. She introduced the salient features of the POCSO and Domestic Violence Acts while encouraging participants to narrate personal experiences of violation, discrimination and violence based on sex and gender.

Value Clarification and Taking Stances

Neeta Karandikar, Associate Director, Anjali Pore, Programme Coordinator and Rama Shyam from SNEHA facilitated a session on enabling the Change Agents to debate, think and share perspectives around a statement “Violence is Justified for the Right Cause”.

A long brainstorming on violence as the language for improving behavior arose during the discussion with each side debating their stand, feeling confused, changing sides and trying to defend personal stances. The key takeaway was that values may be commonly shared and perhaps each side was striving for peace, love, equality and understanding. However, the approaches were different based on different perspectives shaped owing to the differences in the environment that nurtures individuals. Participants analysed the key aspects that go into shaping values and perspectives – family, culture, social structures, school/college, media.

Development Perspectives: Power Structures and Access to Resources

The second day began with an energizer and recap from the previous day. This was followed by an exercise on distribution of and access to resources. Participants could relate with how resources such as educational opportunities, land, wealth, water, health facilities are distributed unevenly. Some participants strongly affirmed the need to work hard to access opportunities.

The next exercise was a power walk that laid bare the social and economic structures that make opportunities inaccessible. It was revealed how population segments such as the homeless, children from marginalized backgrounds, women in general and religious minorities faced discrimination and alienation. Participants cited instances of discrimination against Muslims while seeking jobs and of vulnerability of women and children within homes and outside in the society.

Leadership Styles

This session facilitated by Ms. Anjali Gokarn was extremely interactive with all the participants engaged in a small group activity that clearly brought out the three leadership styles viz. Democratic, Autocratic and Laissez Faire. The Change Agents were encouraged to share their experiences from each group before venturing into the next exercise on how each person must assume a leadership role at various points across life.

Towards the end of the session, each small group came up with a logo and slogan on what the EHSAS project means to them.

Some of the powerful feedback we received from the participants in the workshop:

“This is the first time I realised that I have a right over my body and even a husband/partner cannot violate it without consent”

“I have gained a lot of clarity on gender based violence”

“My key takeaway is that Articles 14 and 15 guarantee equality before law”

“Violence begins with language and gestures used at home and children often learn that this is the only way! Love and understanding are the only ways to break this cycle”



Community Health Workers- change agents and mobilisers


The American Public Health Association defines a community worker as: “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery”. Non-profits working towards improvement of vulnerable population rely on the work of these individuals, to achieve the organization’s mission.

Community health workers (CHW) are therefore fundamental for implementing field-level programming by engaging the community and the beneficiaries through participatory efforts. Carrying out initial work in the community through surveys, house-listing, community mapping, corner meetings, micro-planning etc. are crucial tasks in establishing first contact with the community. Initial community engagement activities carried by CHW(s) include identification of eligible beneficiaries, enrolling them for the sessions, services and trainings. They also mobilize community to participate in group education events and campaigns. Carrying out interventions in the community through group formation, group/community meetings, counselling, information sharing, capacity building, paying home visits, conducting growth monitoring health camps and vociferously following up with individual cases are significant activities carried by them. An important skill that they have mastered over their engagement with the community is customizing the information delivery based on the requirements of the beneficiary. Case management and referrals are other vital tasks carried by them to reach out to the beneficiaries.

A critical area of SNEHA’s research involved analyzing the motivations of these frontline workers, to both take up as well as sustain in this challenging role. As such, a study was created in order to gain insight into the perception of roles and responsibilities by CHWs as well as motivations and challenges they faced. The study comprised of in-depth interviews of the health workers from four NGOs namely: SNEHA, Apnalaya, Foundation for Mother and Child and Shelter Associates, to tap into areas, from background information and training, to personal and organizational factors.

Many themes emerged as to why CHWs decided to join the non-profit sector to begin with. Narratives expressed a desire to contribute to purposeful work, as well as to increase one’s knowledge base from a personal growth perspective. Others expressed support from supervisors as contributing factors to making the decision to join the organization. Another narrative offered willingness to try out work in a new field, and an opportunity to return to the workforce following marriage and motherhood as motivation behind initial association.

Community Health Workers also reported having a positive impact on beneficiaries who engage with trained staff during a critical phase in their growth and development. This, CHWs stated, gave rise to a capacity for self-reflection, increase in knowledge and discernible behavior modification, promotion of healthy relationships through candid conversations between beneficiaries and their parents, and added value through incentivized vocational courses, such as computer literacy and English speaking for beneficiaries. Most importantly, confidence and a personal connection and rapport is built in beneficiaries, and changes seen in youth that push forward that they will go on to produce an equitable society free from gender based or domestic violence.

As for their perceived role, many CHWs believe they served as teachers as well as resource personnel. However, they also believed their responsibilities and scope of influence transcended programming and campaign initiatives. They served as confidants and guides to youth and adolescents by providing them with a safe space, to share their experiences and voice their opinions.

Self-reported characteristics of an ideal CHW included: a strong work ethic, exceptional communication skills, and the ability to generate goodwill through intensive rapport-building efforts in communities. Many front line workers left feeling their own exposure to topics during training left them having not only gained knowledge but also triggering introspection and empowerment within them themselves.

Most CHWs reported having a positive and supportive environment at work and were well satisfied with provisions offered by the organization, including training, timely salaries, flexibility with schedules, as well as staff support and real time feedback.

As for challenges that arose within their work, CHWs expressed the need to juggle multiple responsibilities, thus risking being overstretched. Financial situations also posed a challenge, as did organizational factors.

Perhaps one of the most moving aspects of the study was the participants’ personal account on the changes they had witnessed within themselves, having been part of the organization. While their role was believed to be multifaceted to include serving as a teacher, confidant and guide to the beneficiaries, a significant element that emerged from their personal journey with the NGO was their own process of self-reflection. This manifested in an internalization of knowledge within participants such that through their evolving understanding of themes, empowerment emerged. Affection and respect for working with interacting with children arose as well, contributing to a positive learning environment. Participants also expressed an increase in topical knowledge; skill based competencies, as well as improvements in communication skills and self-confidence. Most importantly, participants saw themselves community resources persons, with one expressing the view of being a change agents, with the ability to empower people in the community.


A step towards empowerment and leadership- Our Sanginis


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Our Sanginis at the Godrej India Culture Lab conference. Photo courtesy: Godrej India Culture Lab (Link:



Godrej India Culture Lab is a Mumbai-based experimental space that brings together ideas and people together to explore what it means to be Indian. It held a two-day conference, ‘We the Nation: Micro-narratives of change’ on June 30th and July 1st, in Mumbai. The conference, showcased organisations that are documenting the rapid changes taking place in India today, through talks, panel discussions and exhibitions. It featured noted journalist, P. Sainath, who spoke about the work he is doing through People’s Archive of Rural India (PARI), Video Volunteers, a Goa-based organisation that empowers marginalised communities to tell their stories, Digital Desh Drive, an annual report that explores how non-metros are using the internet, Khabar Lahariya, a community-run newspaper published by rural women; amongst other path-breaking and inspiring organisations.

SNEHA’s sanginis (women volunteers from the community) attached to our Prevention of Violence against Women and Children program, who identify and map cases of domestic violence, refer cases to our crisis centre for legal aid or intervention and hold community meetings to discuss gender norms, had the opportunity to attend the the conference and participate in a panel discussion. They were accompanied by Meera Sai, Program Coordinator of the Little Sister project  that uses mobile technology to track and report instances of domestic violence in Dharavi.

This was an opportunity for our Sanginis to share their experience in using mobile technology to address the pervasive issue of domestic violence in slum communities. The audience was intrigued to know how Shehzadi, one of our sanginis, who hails from the muslim community, is challenging gender norms. Shehzadi has been part of SNEHA’s efforts in preventing domestic violence for over a decade now. Nikita, another Sangini, shared about how SNEHA has played a pivotal role in shaping her thoughts – ‘Not being educated or not being able to converse in English has not stopped me from being confident,’ she said while telling a tale about how she fought with her family and supported her daughter to pursue higher studies.

For our sanginis, who work on challenging patriarchy and social norms everyday, the conference was a validation of their inspiring work as well as an incredible platform to share their stories. Empowering women and developing grassroots’ leaders is the core of our work in preventing gender violence and platforms like these, are where we want our sanginis to be!



How a Community Worker has the power to help vulnerable women make better health choices

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“Health cannot be bought at the supermarket. You have to invest in health. You have to get kids into schooling. You have to train health staff. You have to educate the population.” – Dr. Hans Rosling, Swedish Global Health Scientist

Mumbai is a truly fascinating location for a case study in Maternal Health due to the large number of coexistent inequalities when it comes to women’s health. The city boasts of world-class health facilities, yet struggles with equitable health distribution for a majority of its citizens. The country’s second largest city has a population of approximately 12.4 million, more than half of whom live in informal settlements (colloquially known as slums).  Some numbing statistics include: Only about one-fifth of dwellings in informal settlements have a private toilet, only 31% of residents have completed 10 years of education, and the total fertility rate is below the replacement threshold at 1.9. The 40% slum dwelling population, including the often-discounted migrant populations, are often shortcharged by the quality of public health services. One of the major reasons for the lack of accessed care is that awareness, uptake and knowledge levels among many of the users of public health services typically tends to be low, especially, in informal settlements in urban areas. Female literacy is only 54%, and women lack the autonomy to make decisions, that affect their own bodies. On the supply side, quality of health services tend to be sporadic and inconsistent.

As part of my research thesis field work, I spent the Summer of 2016 working with a Mumbai-based non-profit, Society for Nutrition, Education and Health Action (SNEHA) that believes in investing in women’ health in vulnerable urban slum communities in four large women’s health areas, Maternal and Newborn Health, Child Health and Nutrition, Sexual and Reproductive Health and Prevention of Violence against Women and Children. In SNEHA, I spent most of my time understanding how they work through their community staff, known as Community Organisers, to motivate and educate their beneficiaries (typically residents of vulnerable pockets in poor urban communities) and nudge them towards better care-seeking behaviour.

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Community organizers hired by SNEHA are members of the community who are trained to provide education to expectant mothers in the area through door-to-door educational interventional programs. Community Organisers also work with health systems, by training, up-grading and building capacity of health workers attached to these systems.

Through my field work, it became abundantly clear that maternal education programs in urban Mumbai work due to the close relationships that are forged between the Community Organizers who work intimately with beneficiaries from vulnerable communities. While studying the various forms of beneficiary compliance and behaviour change, I was able to track that the relationship between the community organizer and the mother was the main determinant in the level of compliance. Even in the least compliant measure of cultural compliance where mothers are expected to follow medical instructions instead of harmful cultural practices, mothers with the most visits from a community organizer were most likely to follow instructions that most mothers in that cultural climate would not. To improve compliance, SNEHA would have to increase the number of times the community organizer meets the mother, and start the antenatal care as early as possible.

The public health system has a negative perception among its users. Previous experiences including long wait-times, lack of required resources, bad behavior by staff and unnecessary referrals, further adds to these perceptions. This prevents pregnant women from seeking regular antenatal care and seek follow-up visits. One of the ways we could prevent loss of follow-up is to enable Community Organisers to accompany pregnant women for their antenatal check-ups. This could start a smooth initiation into the antenatal care process. SNEHA already works with the public health system and intervenes, setting up and managing referral works while working with health posts so that they can handle basic antenatal check-ups. Another intervention mode could include training public health staff in soft skills including patient interacting, communication and information sharing.

Maternal deaths are preventable. Safe motherhood can be achieved as a goal with access to quality institutional care for mothers with complications during pregnancy. Availability and accessibility of skilled birth attendants, basic and comprehensive emergency obstetric care, around the time of birth is also critical. A large proportion of newborn illnesses and deaths can also be prevented using simple, low-cost interventions during delivery and during the week following birth partum, provided both in the facility and at home (where currently 50 per cent of newborn deaths occur). SNEHA’s community workers achieve these aims by their relentless efforts to educate the most affected populations. Education improves health, while health improves learning potential. Education and health complement, enhance and support each other; together, they serve to improve quality of life for women and children in developing countries.

By Shikha Chandarana

Shikha is an undergraduate student in Brandeis University, US. She was a research intern at SNEHA in 2016.

All opinions recorded here are of the author and don’t necessarily reflect SNEHA’s views and opinions at all times.

Not a ‘private matter’

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By Rahul Thekdi

An abundant amount of written content, a robust set of laws and several promising media campaigns have all been unable to combat the problem of domestic violence at its root cause. Mostly shrugged off as a ‘private matter’ by men, the victims who in most cases are women, are yet to speak openly about the ill treatment faced by them behind closed doors.

The social evil, which affects both rich and poor equally, has denied many women the basic human values of respect and freedom of individuality thus restricting them to caged framework of conduct laid out by the society. Not only do these women succumb to physical injuries but also face long lasting negative impact on their mental health as a direct consequence of the abuse.

Women who are victims of domestic violence are more vulnerable to depression and anxiety among other psychological consequences. Domestic violence is also associated with a thread of fatal consequences such as chronic pain disorder, sexually transmitted infections including HIV, unwanted pregnancy, miscarriage, complications during pregnancy which may also lead to substance abuse and suicide.

There have been relatively very few studies in India throwing light on the men’s perceptions as to why they inflict violence on their spouses. In this backdrop, to engage men in bringing a positive change in their behavior towards nonviolence, a study conducted by SNEHA in which it interviewed 13 male participants revealed that primary cause of violence lies in the notion of male superiority and authority over his spouse’s conduct. The deeply ingrained patriarchal social system is to be blamed; it creates a permissive environment for spousal abuse.

In order to sooth the male ego, any act of disobedience or mistake by the woman, form the basis of his right to use force in order maintain his dominance within his marriage.

Another very important parameter is societal pressure, which causes instances of abuse by men so as to keep intact their image in the society. Men justify these acts by simply labeling it as social norm and any act of outsider’s/natal family’s intervention or contact with the police is considered as a threat to the marriage.

The study found out that a section of these men who accepted the blame cited stress and frustration as the primary reason to resort to violence. In fact, according to the study, men who undergo stress are more likely to be abusive than those who do not undergo stress. Stress is caused mainly due to economic hardships, difficulty of coping with urban lifestyle and lack of personal space. The study found that men hesitate to share any of these stressors with their friends or family for fear of being labeled ‘weak’.

The need for the hour is to break the societal barriers and create an environment for men to openly discuss their problems. Counseling these men to help stop the violent behavior and build a nature of acceptance rather than denial is the key. This could only be done through opening up and letting the partners share their feelings and as an intervention, provide a helping hand through effective communication, self-control, anger and stress management workshops.

Simply labeling the men as violent partners is not the answer to solve the problem; an intervention is required to bring about an effective communication model and to provide them a platform to voice their concerns which will in turn help change their outlook towards domestic violence.

What needs to be understood are the reasons for the aggressive nature and their source of frustration in order to deconstruct their existing concept of masculinity.

These angels live on the ground – A Women’s Day Special

Ten years ago, Archana Ramesh Mahapade, 50, was out on a fund collection drive when she saw a large group of women.

“When I saw the line and the women waiting patiently, I became curious. I joined them and found out that interviews were being conducted for the position of a community worker at SNEHA. I was selected and that is how my journey began.”

Archana Ramesh Mahapade, Community Organizer, SNEHA

It is community workers like Archana that help drive the impact of SNEHA, Society for Education, Nutrition and Health Action, an organization that for many decades now, has been working towards improving the health of women and children in slum communities.

SNEHA’s community centres in the vulnerable areas are key to driving the program. The community organizers are drawn from the community itself, and their ease and familiarity with the local population makes them an invaluable asset.

However, as Anupama points out, the familiarity does not guarantee that their presence or advice is always accepted.

“When we first tell people about SNEHA and the work we do, many look tense and turn away. Some women even shout at us and we do feel bad. But we always come back the next day. Eventually their attitudes change when they realize that we are there for good, and not just for a day.”

Once the ice is broken, it takes a few more sessions before they start talking about their lives. “Initially, when we ask them about family planning methods, they are not honest. They say everything is good but as we probe further, we get to know about the situation at home, the pressures they face.”

Building this intimacy is critical given the many levels of SNEHA’s intervention. It goes beyond maternal and newborn health to child nutrition, and sexual and reproductive health, issues that girls and women have never been encouraged to think about. SNEHA offers crisis intervention, counseling, medical and legal help to survivors of violence. It also works on prevention in communities and enables government systems to respond in an effective and sensitive manner.

Access into the homes and lives of women here is vital,  and the community organizers enable that.

Saira Shaikh, CO, Govandi

“The women in my area come to the city after marriage and they are lonely and unaware”, says Saira Shaikh, 38, a community organizer at Shivaji Nagar in Govandi. Govandi, one of Mumbai’s largest urban settlements, is home to a large population of migrants, who depend on odd jobs to make a living.

“They face violence at home and have no one to turn to,” adds Shaikh. “The violence is made worse by the low unemployment levels. The husbands spend the daily wages on other women or on drinking. We give these women strength by telling them to come forward and seek help so they can start providing for themselves and their kids. We also encourage them to stand up to their husband. Over a period of time, they start to listen and assert themselves. “

Often it can take as long as two years for behaviour change to set in.

Saira brings up the case of a woman in Shivaji Nagar who was pregnant with her fifth child. Her hemoglobin count was just 7.6 and she was always complaining of feeling dizzy and weak.

“The husband would shout at her for being lazy and as we started visiting her we realized that she hadn’t even registered her name at the local hospital”, says Saira. “This was because her husband would not give her money even to go to the hospital. She was a victim of domestic violence. Her husband would even shout at us when we paid a visit. ”

Saira finally took the help of a senior SNEHA staff member to convince the husband. “We were very patient and calm but it still took three months to get him to agree to a hospital delivery. In the meantime, we took the help of the local municipal health staff and started giving her injections and monitored her diet closely. Because she had little money, we encouraged her to eat dates, which are cheap but high in nutrition. She was able to have a healthy baby. “

The episode offers a glimpse into the level of focus and dedication that the community organizers bring to the job.

“In my experience, women and children’s health is an issue everywhere, “ says Archana. “The kids are weak but the mothers don’t think anything is wrong because they compare them with other kids in the neighborhood. They don’t realize that their child has not met important growth indicators. “

Given the sensitivity of such matters, I ask Archana how she speaks to the mothers without making them feel inadequate.

“When we talk to the women, we ask them what the kids eat and the answer almost always is – “I cook but he doesn’t eat what I make”. Then we ask if the kids have been given pocket money that day. The mother realizes that the child has spent the money on buying snacks, and does not want to eat what is cooked at home. We get the mothers to stop doing that. We also show them ways to cook such that the food is to the child’s taste. Like to partially fry an egg and add the roti so the child gets protein and carbohydrates. We have been able to encourage all the women to breastfeed, which was not the practice earlier.”

Ask Archana what difference being a community organizer has made, and her face lights up.

“I am so proud to be a CO. I have helped women who have suffered multiple miscarriages, deliver healthy babies. I have also been able to help couples conceive by telling them about ovulation. The money may not be much but the satisfaction is huge. It has helped to build ties within the community. Now when I don’t go to the community even for a day or two, the women tell me you haven’t come for so many days,” laughs Archana.

SNEHA – A community-based health model that delivers

Public health in urban areas is one of the most persistent, yet neglected, issues facing the developing world. Cities present an especially challenging canvas given the many different factors – migration, inadequate housing, lack of infrastructure, crime, political corruption, pollution, and dysfunctional health systems – that are in play.

Over 50% of the world’s population lives in cities and this number will rise in the next few decades. Due to migration, India’s cities are growing more than three times as fast as the rural areas, and it is likely that more than half of the country’s population will live in urban areas by 2050.

The factors that affect human health are many, ranging from climate change and greenhouse gas emissions to reproductive health and rights. Meeting them is key to India’s success in achieving universal health coverage and improved national health indicators.  96-of-109

The National Urban Health Mission in India aims to enable rightful access to quality health care. This is by setting up an improved public health system, partnerships, and community-based mechanisms. This is to be done with the help of secondary and tertiary institutions, urban health centres, and community outreach. The positive outcomes of such a partnership in Mumbai’s urban settlements, demonstrated by SNEHA, is the subject of a paper recently published in the prestigious medical journal The Lancet.

The interventions of the Society for Nutrition, Education and Health Action, SNEHA, interventions are born out of 16 years of work with women and children in informal settlements. They range from maternal and neonatal health, sexual and reproductive health, childhood nutrition, and prevention of violence against women and children. What makes SNEHA’s model unique and effective is that it integrates these activities, and the model can be replicated in urban settlements across India, perhaps in many developing countries as well, with some tweaks for local, cultural specifics.

SNEHA’s adoption of an integrated approach came after a large neonatal trial conducted in Mumbai. It was felt that this would be an effective method given the multiple health issues faced by women and children, and the belief that communities would be more responsive to an intervention that had both, physical presence and service delivery.


Every SNEHA centre is equipped with three full-time community organizers with backgrounds similar to the people they reach out to. They are trained to bring together the themes of reproductive, maternal, and neonatal health, child health and nutrition, and prevention of violence against women and children into the community services. They are responsible for home visits, group meetings, organizing day care for malnourished children, and community events, in close association with existing systems.

A survey was done before, and two years after SNEHA’s intervention on three main outcomes – family planning in women (15–49 years), immunization of children, and wasting among children less than five years. The survey looked at secondary outcomes as well, like violence against women or children, number of home births, pregnancies in women younger than 20 years, to name just a few.

There were significant improvements in the met need for family planning, and full immunization. Compared to the NFHS 2015-16 figures of 14% unmet need in Mumbai, the results in the areas of intervention was 22%. Again the NFHS-4 findings showed that 46% of children between 12–23 months in Mumbai were fully immunized. Contrast that with the intervention area rates of 69%. The findings were similar when it came to wasting in children, and diet among children.

There were other positive fallouts seen as well like the use of sturdier material to build homes, building of private toilets and use of safe, drinking water.

The challenges of meeting the health needs of settlements in an urban milieu are many. The shifting nature of the population and specific cultural beliefs can often slow down rates of progress. However, the overwhelmingly positive outcomes demonstrated by SNEHA’s model shows a way forward to city governments across developing countries who are grappling with ways to improve health in informal settlements.

Link to The Lancet paper –

When classrooms promote patriarchy

That sexism and patriarchy is deeply ingrained in India is not a matter of debate. But when actively promoted in school textbooks, it becomes a matter of grave concern.

There is much outrage and sarcastic humor over the recent news report about a Class 12 textbook in Maharashtra that lists “ugliness” as a cause of dowry.

To elaborate, the sociology textbook says – “If a girl is ugly and handicapped, then it becomes difficult for her to get married”. It follows this up by saying that families of such girls feel helpless and end up paying more dowries.

The battle against patriarchy, as many NGOs working on the ground will attest, is a long, uphill one. It’s a fight to change mindsets that develop and are fostered at homes – attitudes that both genders are equally guilty of propagating.

Imagine the impact then of school textbooks on deeply impressionable young minds? They should be agents of change. However, instead of damning a system that places girls in a secondary role and fosters practices like dowry, our textbooks are promoting regressive attitudes.

This is not the only textbook guilty of promoting such pearls of wisdom. Read this gem from a textbook in Rajasthan – A donkey is like a housewife … In fact, the donkey is a shade better … while the housewife may sometimes complain and walk off.. You’ll never catch the donkey being disloyal to his master.

A three-year-long study on Indian education, which looked at 22 English and 20 Hindi textbooks, stated that the authors of school textbooks showed a deeply patriarchal mindset. Women are shown as weak, in need of protection and capable only of staying at home.

A study by UNESCO of school textbooks from across the world found that many of them are deeply gender biased and undermine girls’ motivation, participation and performance in school. Regarding India, it said, “half the illustrations in elementary English, Hindi, mathematics, science and social studies textbooks depicted only males”.

The subliminal messages these books reinforce is that of a patriarchal world, where women are capable only of playing secondary, submissive roles. Attitudes are shaped early and such messages at the school level have a dangerous impact, substantially undermining the fight against gender discrimination.


Why Family Planning must be key priority in Budget 2017

Just this month, a woman died and five others were critical after a surgery at a family planning health camp in Maharashtra’s Yavatmal district went horribly wrong.

The woman who died was just 36 years old. The death, according to reports, occurred because the government doctor at the Primary Health Centre cut the intestine instead of the fallopian tube while operating on her.

The tragedy brings home the critical gaps in India’s family planning programs especially in large parts of rural India. Given this, it is important that the government prioritizes family planning in the upcoming Budget to ensure that young couples are offered information about, and given access to FP options.

In 2015, the Health Ministry announced some welcome measures in this regard, like expanding the basket of contraceptive choices and ensuring their availability in district hospitals. There are now three spacing methods of contraception in the government FP program – Centchroman, Progestin Only Pills, and injectable contraceptive – offering greater choice and independence to users.

But India is still way short of the commitments it has made under FP2020. At the 2012 London summit, the country had promised to provide FP services to an extra 48 million new users by 2020.

The progress report in 2015-16 shows just how far we are from that goal. Less than eight million extra users have been catered to until July 2016. To meet the targeted numbers, the government has to allocate more resources towards meeting the FP needs of the population.

Census 2011 showed that over 10 crore girls in India get married before they are 18 years old. Young couples, across communities, come under great pressure to have a baby within a year of marriage. Many of them want to delay babies but don’t have the information or access to do so.

Expanding contraceptive choices for men and women while important is not sufficient by itself. They have to be empowered about exercising these choices and this has to be done through sustained community awareness campaigns by the government, civil society and other stakeholders. This needs extra staff on the ground and therefore more funds. The budgetary allocations to health and FP need to be substantially hiked.

India spends just 1.3% of its GDP on healthcare, a figure far lower than countries like Bangladesh, Brazil, Russia and China. Even Afghanistan and Nepal allocate more. Budget 2017 needs to address this shortfall.

Unsafe abortion – A major risk in India

Just how grave a threat unsafe abortion is for women is brought home in the data that 10 women die everyday in India. The country sees over 65 lakh pregnancy terminations every year. Unsafe abortion ranks as the third leading cause of maternal deaths in India. Hence access to safe abortion methods is critical to prevent these deaths.

In this context, the US President Donald Trump’s decision to bring back the Mexico City Policy, popularly called the Global Gag Rule, has major implications for women around the world, including India.

The Mexico City Policy is a US government policy that requires foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” with non-US funds as a condition for receiving US global family planning assistance. As of January 23, 2017, this includes any other US global health assistance, including HIV and maternal and child health (MCH).

The rule is a dangerous move against reproductive rights, as organizations will now have to choose between receiving American foreign assistance funds and providing comprehensive care. It dictates to foreign NGOs not just how American aid is to be used but also lays down that they must not spend their own money on providing abortion, and abortion-related services.

Poor or no access to contraception and safe abortion is a major public health crisis for women in the poor countries. The Global Gag Rule puts them in more danger as it puts them at risk of unsafe abortions.  The policy change will lead to the withdrawal of aid set aside for contraceptive access as well as comprehensive abortion care worldwide.

Once again politics has prevailed, and with the stroke of a pen powerful men have decided the reproductive rights of millions of women across the gobe.This is a move that affect women’s health and endangers their rights and independence. And the impact is widespread and damaging as it is well documented that giving women control over their reproductive health, improves not just the health outcomes of mothers and children but is key to economic progress.

Innovative approaches to tackling malnutrition

The malnutrition-related deaths of nearly 600 children barely 100 kilometres from Mumbai in 2016 underlines the critical need for various stakeholders to come together to find ways to bring about behaviour change, and ensure that benefits charted out under various government schemes actually get to those who most need them.

The fact is that children do not die of malnutrition but of causes due to malnutrition. Stunting is a better indicator of malnutrition and according to studies 51% of children and adults among tribal populations in Maharashtra are undernourished and stunted. This is a significant figure and one that has not shown sufficient improvement in the last few years.

Across India, the occurrence of wasting among children is serious. Even within the limits of the financial capital Mumbai, NFHS-IV shows that one-fifth of children under the age of five years suffer from wasting. This is very serious indeed given the associated risks of disease, even death, among children who are very underweight.

Since 2011, a program introduced and managed by SNEHA and CRY has shown the way forward when it comes to tackling urban malnutrition, especially wasting. Over a period of two years, the percentage of wasting in children reduced sharply from 18% to 12% in the slums of Mankhurd, Govandi and Kurla situated in the suburbs of Mumbai. SNEHA’s intervention in child health and nutrition in Dharavi showed equally encouraging signs – a fall of wasting from 18% to 13%.

The percentage of children who received full immunization rose from 66% to 73% in the three areas mentioned earlier. There were also other positive changes, like rise in hospital deliveries (12 up to 15%), adoption of family planning methods (34% up to 59%) and a dramatic drop in pregnancies among women below the age of 20 years. (17% up to 4%).

The changes took place because of a sustained merging across different sectors at the community level to enhance child under-nutrition. This was backed up with enabling behaviour change through home visits, one on one counseling, awareness campaigns, and community meetings. This led to greater adoption of FP methods, immunization and better nutrition practices.

Urban malnutrition is a challenge not just peculiar to world cities like Mumbai. Tackling it requires innovative and creative approaches that take the community’s needs and pressures into account. The program by SNEHA and CRY offer a window into an approach that could show results in many parts of India to reduce malnutrition rates.




‘The Sanginis are truly the heart and soul of the Little Sisters project’


SNEHA had launched the Little Sister Project as part of its Prevention of Violence against Women and Children program in 2014. The Project uses mobile technology to track and report domestic violence in Dharavi, and to seek intervention during crisis. Damini Mohan, who coordinated the project for 18 months, recently left to pursue higher education. She agreed to speak to us about the highs and lows she felt while coordinating this important and one-of-a-kind intervention.

Q) What were some of the challenges you faced in coordinating the implementation of the ‘Little Sister’ Project?

Damini: One of the biggest challenges I faced was addressing  technological malfunction. We built a customized interface with the help of a tech developer which was occasionally prone to bugs. With almost 100 live users, managing the tech ‘crisis’ while ensuring work doesn’t get hampered for our Sanginis (community workers), field staff and counsellors was an exercise in enthusiastic team work, logistics and keeping up spirits!

Q) In terms of implementing a mobile technology project in a low resource context, what have your stand out learnings been?

Damini: I think it is important to acknowledge the significance of giving a smartphone to a woman in an urban informal settlement in modern India. Along with reporting cases on the Little Sister app, Sanginis used the smartphones to Google recipes, manage household budgets and contact family and friends on Whatsapp. Digital literacy was an unplanned though welcome outcome of the Little Sister project. The one drawback was the never-ending high phone bills which SNEHA was footing. We revised the data plan, shifting from postpaid to pre-paid to ensure the project remained low-cost while offering Sanginis opportunities to explore and learn about the digital world.


Q) Could you elaborate on some of the art-based activities you piloted in the community?

Damini: During this year’s 16 days activism, four Sanginis faciliatated an art campaign, “Mera phone, meri kahani”. They felt that as Little Sister Sanginis, they were confidantes of women facing violence and the phone was like a box of secrets. They worked with community women to create ‘phones’ out of shoeboxes, each with a story of violence inside. The participants enjoyed crafting the boxes and creating a story to put inside the box. The Sanginis, facilitated the session were confident, eloquent and demonstrated excellent leadership skills!

Q) Personally, what has been the one gratifying thing about running the Little Sisters project?

Damini:  It has been very gratifying to work with an excellent team, both the staff at SNEHA as well as the Sanginis who are truly the heart and soul of the Little Sisters project. Their fierceness to speak out against violence, commitment to help out women and children in distress, their curiosity and zeal about technology and their formidable spirit will stay with me for a lifetime. It was an honor and a privilege to work with them!

Thank you, Damini! Wishing you the best for the future!

Need to rethink approaches to infant & maternal healthcare

The figures reporting the decline in infant deaths in India is something to celebrate. Data for 2015 shows that 27 babies died for every 1,000 births, which is two better than the government’s own projected figures.

That is a drop of 53%, which is still far short of 67%, which is what India had promised to achieve under the MDGs. But it is promising in that it shows government programs to reduce baby deaths like incentivizing institutional deliveries, providing supplements to pregnant women, etc., is having some impact.

Data from states like Goa, Manipur and Punjab, which have reported a drop of over 60% in IMR is especially promising. However, compare this to the high rates in Uttarakhand and Madhya Pradesh and one gets a picture of just how patchy and uneven the quality of healthcare services remains.

This is a critical lack and needs to be addressed, as high IMR is a report card of the health of the country and an indicator of the future growth potential. Clearly policies aimed towards maternal and infant health need a rethink given the huge gaps that exist.

While widespread illiteracy, poor nutrition and sanitation, and lack of awareness are key factors that explain the high rates, the poor healthcare infrastructure on the ground is evident in the high number of deaths reported from states like Odisha, which witnessed the deaths of over 50 children in just two weeks in a state-run children’s hospital. 151 deaths were reported across hospitals in Kendrapara in Odisha in just 4 months.

There is a need to address the system on the ground and look at what the shortfalls are. Maternal and child health policies cannot work in isolation. There are important connections between these groups and there is a need to strengthen the continuum of care to ensure that an unbroken curve spans the home, community, health center, and hospital. This would help manage the maternal-newborn-child health scale of care in a more unified way.

A compelling case for contraception

Recently Melinda Gates made a compelling, passionate statement about how giving millions of women access to contraception was necessary to end poverty and disease for both present and future generations.

The Bill and Melinda Gates Foundation, of which Melinda Gates is co-founder, has made it a mission to ensure that millions of women in developing societies have access to safe birth control measures. Since 2012, Ms Gates has been leading a worldwide campaign to get 120 million more women access to birth control by 2020. The BMGF has donated over one billion dollars towards family planning.

Never before has this fight for a woman’s right to decide if, when, and how many children she wants to have been more important. The recent India wide study on how ten million women in the country are forced to resort to unsafe abortions every year underlines the critical need to make contraceptive options available.

The study, done by the IndiaSpend team, highlights that myths and misinformation about contraceptive methods are still widely prevalent despite India having the longest government-backed family planning campaign in the world. Millions of women still lack access to contraceptive options. They are left with no option but to take over-the-counter pills or undergo dangerous, unhygienic surgeries to end pregnancies.

A 2016 Lancet report highlights how distant the prospect of safe abortions remains for rural Indian women. This is the case even nearly five decades after abortion was legalized in India. In the absence of safe methods, sales of popular abortion pills remain abnormally high.

Widening the basket of contraceptive choices, as the government did earlier this year, is a much welcome, long overdue step. But to be truly effective, these choices have to reach the millions of women in our smaller towns and villages. That needs better delivery systems, better training of doctors, and a mass awareness campaign. All of which remains a giant, gaping hole in our FP program.

Ehsaas: Making Boys Part of the Solution

It is now widely recognized that improving the status of women has to involve boys and men. As much as girls, boys too are trapped in stereotypes and they need to recognize and value the importance of building equal and healthy relationships.

Unequal power not only suppresses women and girls, but also oppresses men and boys. Apart from the pressure of being the economic provider, rigid gender roles also limit men’s cultural experience. There is the pressure to appear virile and strong at the cost of suppressing emotions.

Since 2013, SNEHA’s Ehsaas program has been working among adolescents in Mumbai’s slum communities towards breaking these stereotypes. Through a mix of street plays and community sessions with adolescents and their families, gender stereotypes are questioned and challenged.

“The attitude has been to look at boys as problems”, says Neeta Karandikar, associate program director, Ehsaas. “This is especially the case after the Nirbhaya and Shakti Mills incident in Mumbai where the accused were from the slum areas. Boys from poorer communities were seen as problems. But we have to recognize the challenges they deal with”.

Traditional patriarchal attitudes, believes Karandikar, not only oppress women but act as traps for boys and men. By highlighting norms that allow boys to play while girls do hosuehold chores, Ehsaas encourages youngsters to question prevailing mindsets.

“My sisters would eat only after the men of the house would finish their meals”, says Shahid Shaikh, a peer educator with Ehsaas. ‘I never questioned that. It was after I joined the program that I realized how wrong this was and I now make sure they eat with everyone else”.

For decades, gender equality was considered a woman’s issue. Now, there is a realization that the role of men and boys in challenging and changing unequal power relations is critical. There is a stronger focus on the positive role men and boys can play in promoting women’s empowerment in the home, community, and  workplace.

To know more about Ehsaas, read this NDTV report 

Putting Health at the Heart of Urban Planning

The recent series by the Lancet on urban slums highlights the importance of placing health at the heart of all interventions.

Over 800 million across the world live in slums; areas where expansion happens with not enough planning or infrastructure. This is despite the many specific challenges that come with slums, like poor housing, unsanitary living conditions, overcrowding, lack of basic health and social services.

These are serious, crippling challenges that need to be addressed and planned for as they are preventing millions from reaching their full potential.

There is a need to put health at the heart of urban planning, argues the Lancet series, an approach that organizations like SNEHA are consistently working towards. Urban public health is one of the most persistent yet disregarded issues facing the developing world. However, there has been no inclusive plan for dealing with India’s rapidly urbanizing population.

The primary focus remains rural health, and while this is important, there is a need for an urban health agenda given the many challenges in our cities.

Take Mumbai’s slum population. They are regarded as a homogenous, indistinguishable presence, although they are a vital component of the financial capital’s economic productivity. Many of them live day-to-day, rather fragile existence with poor access to amenities like drinking water.

The World Health Organization’s report – Health as the Pulse of the New Urban Agenda also reinforces the need to put health at the heat of urban planning. Urbanization, it says, comes with opportunities for mobility and economic growth but has a negative impact on health and the environment. For urbanization to become sustainable, measures have to be put in place for disease prevention and health improvement.





State of India’s Children

In less than two weeks, India will celebrate Children’s Day. There will be programs held and speeches made on the treasures that our children are and the tremendous potential they hold for our country’s future.

It is also a good time to take a hard look at the plenty we don’t seem to get right when it comes to our children. Recent Census 2011 data says over 77 lakh Indian children are forced to earn a living as they attend schools, while over eight crore kids don’t go to school at all.

The fact that so many children are still forced to work is troubling, because it is an indication of the low priority education receives among so many. It is also an indicator of just how unaffordable education is for so many in our country.

India’s under-18 population is the highest in the world, what we pride as our demogrpahic dividend. Then why do they get such low priority when it comes to education and health?

A large percentage is marginalized for reasons like poverty, disease, malnourishment and conflicts. States like Assam, Madhya Pradesh, Bihar, Haryana, Uttar Pradesh and even prosperous Gujarat lag far behind some African countries when it comes to infant mortality. Over 16 million girls between 10 and 19 years are married, many of them to older men.

When it comes to investing in this fragile and critical age group, we are severely wanting at many levels.


Malkangiri deaths: The deadly link between malnutrition & disease

The deaths of 61 children due to an outbreak of Japanese Encephalitis in Odisha’s Malkangiri district brings home the gaps that lie in the health care system in large parts of rural India. Over 100 villages across seven blocks in this region have been hit and unofficial reports are that the number of children who have died is much higher than 61.

Japanese Encephalitis, which affects mostly children, derives from pigs and spreads to humans through mosquitoes. The population in this part of Odisha is especially vulnerable as people here depend on pigs for livelihood.

There was an outbreak of Japanese Encephalitis in 2012 as well that led to many deaths. Despite that, the community remains unaware of the dangers of rearing pigs so close to their homes. The administration has also failed to carry out door-to-door monitoring for fever and monitoring.

The apathy is even more shocking when one looks at the data. Malkangiri ranks among India’s top 15 districts when it comes to child wasting, stunting and underweight. One-third of children here below five years of age suffer from wasting, stunting and underweight, mainly due to under nutrition.

The infant mortality rate is reported to be 48 as against Odisha’s average of 56, while the maternal mortality rate is 245 as against the state average of 230.

Given the prevalence of so many red flags, it is shocking how poor the health system on the ground is. Malkangiri district has only one pediatrician while the community healthcare centre at Korkunda, the most affected area, has no doctors. In all, 2,000 posts for doctors are lying vacant in the state.

Reports are that vaccinations are very rarely given even if the government has declared a program. Vaccination for JE in India was launched in 2013, but Odisha is yet to receive it share. According to the government’s reports, less than one-third of Malkangiri’s population is covered under the immunization programme.

Regions like Malkangiri show how far we are from providing equitable development across India. Unless steps are taken to strengthen healthcare infrastructure and enable the poor to take care of the nutritional needs of their children, routine epidemics will continue to take away lives.


Giving Girls a Voice

Just how distant a dream going to school remains for girls in India is borne out in the new data on female literacy.

According to this study, the proportion of girls who finished five years of primary school in India is 48%, which is far lower than Nepal (92%), Pakistan (74%) and Bangladesh (54%). The data also shows that only 15% of Indian women who studied till Class II can read a sentence.

Gender, location and poverty remain such huge barriers for a majority of girls in India today. The bias against educating girls keeps them vulnerable to female infanticide, early marriage, gender violence, and sex trafficking.

This can only change when education comes to be seen as a vital necessity for everyone, regardless of gender, rather than an advantage that only the privileged have.

Investing in every girl’s education has to be seen as critical for social and economic development, for lifting households out of poverty.

Educating girls is necessary to reduce the number of child marriages, which remain high in large parts of India even today despite being against the law. Studies show that women who get a secondary school education are 92% less likely to be forced into an early marriage. This in turn makes them vulnerable to early pregnancies, domestic violence, HIV and depression.

Education also has a direct link to lower maternal and infant mortality rates. It helps build awareness about better hygiene, vaccinations and nutrition. It enables more informed choices on matters like family planning and employment. Studies show that women who have had the opportunities to go to school are two times more likely to send their own kids to school.

All of which make compelling arguments to ensure we do more to send every girl in India to school.




Junk food and its health implications

We are all vulnerable to junk food. It’s so much easier to cook and eat a two-minute packet of noodles, or pop some biscuits into your mouth than have to think about what to cook everyday. And with the large varieties of so-called healthy alternatives available, it is easy to get sucked in.

Just how all pervasive junk food is, hits you most outside schools and college. Take a walk around lunch break or after school hours, and you will inevitably find kids clutching packets of chips, or wolfing down vada pavs.

An occasional indulgence is fine, but if eaten on a regular basis, junk food has enormous health consequences, even more so for kids. The World Obesity Federation warns that unhealthy eating, and this includes the consumption of sugary drinks, is leading to a rising number of children becoming obese. Millions are getting affected by Type 2 diabetes and high blood pressure, earlier seen in adults only.

About 13.5 million children have weakened glucose tolerance, which is a sign to diabetes. Over 20 million have high blood pressure while over 30 million have fatty liver disease. This is a condition that is linked to alcoholism and can lead to cirrhosis and liver cancer.

This is bad news for kids the world over. For poorer countries like India, where the health system is already overburdened, it spells disaster.

As an IndiaSpend report pointed out, obesity exists alongside stunting in India and there are serious implications if action is not taken to correct this. Childhood obesity, says the study, is high among the affluent and urban, upper classes. However, there is are not enough studies done on the prevalence. According to one report, India sees 10 million cases of childhood obesity every year.

There is also an alarming rise in cases of childhood diabetes, which needs to be addressed. Clearly an action plan is called for to deal with the WHO has called “an exploding nightmare”.


Need for new approaches to end stunting

The start you get in life determines the future course not just for an individual but for a country.

Just how critical that is, is brought home in a series of research papers published in the medical journal Lancet earlier this month.

The research says that children who lose out on that early start, that is, they are deprived of the required nutrition and care, go on to earn 26% less on average than others. This applies to 250 million children across the world, over 40% of them under the age of five years. This is because stunting and acute poverty will act as a barrier in the way of them realizing their full potential.

Just how critical the need to invest in the first two years of a child’s life has been shown time and again in many studies. The nutrition children get in these years determines not just physical, but also mental growth. Addressing those shortfalls at a later stage is not possible, especially when it comes to cognitive or reasoning abilities. The human brain develops faster at conception and through the first 2-3 years of life.

In terms of numbers, we are looking at 250 million adults unable to realize their full potential. Economically, this translates into income loss and low productivity.

India needs to act quickly if it wants to halt this social and economic loss. The cost of not taking steps to reduce stunting in children, is said to be 8.3% of India’s GDP. We are looking at this lack of action affecting future generations.

A change in approach is called for. Perhaps there is a need to look at programs followed in countries like Peru where under a World Bank-supported program, conditional cash transfers were given to mothers of stunted children. They were also educated about the importance of giving nutritious foods to their kids. Incentives were given to health clinics to support them. The monthly payments depended on how the children progressed.

There is a need for a relook at early childhood and maternal care programs because clearly they are not doing a good enough job of reaching thousands of mothers and babies, especially in large parts of rural India.


Build a conversation on mental health

The recent countrywide survey by the reputed National Institute of Mental Health & Neurosciences, Nimhans, is a wake up call to how lifestyle changes are having an impact on the mental health of Indians.

The report says that a shocking 13.7% of India’s general population suffers from some form of mental illness. A majority of them, over 10% are in need of urgent medical intervention, which translates to about 150 million Indians.

Nearly one in 20 people suffer from depression. Women between 40-49 years are especially vulnerable and report high rates.

Despite being among the first countries to develop a national mental health policy, this is the first time that a proper, in depth study has been done to understand the spread of mental illness in India. Earlier studies at the state levels had several loopholes.

The incidence of mental illness is especially high in urban areas, which is perhaps only too obvious given that is here that the impact of lifestyle changes, changes in family support structures and issues related to job stress are most apparent.

The report raises red flags on many fronts. One is the sheer scale. The other is the huge gap in terms of treatment. This extends to both mental health specialists as well as institutions.

A 2013 government of India study said that there are 3,800 qualified psychiatrists in the country as against the required 11,500. When it comes to clinical psychologists, the requirement is 23,000. The availability is 850. The figures for psychiatric nurses are equally dismal.

The other alert is the widespread stigma attached with mental disorders. The Nimhans report says that 80% of people suffering from mental disorders had not received any treatment despite suffering for over a year.

A major step towards ending the stigma is to build a conversation around mental health. In this regard, it is encouraging to see celebrities like Deepika Padukone come forward to talk about their struggles with depression. It’s a small step, however, given the sheer scale of the mental health crisis India faces. There is a need to look initiatives by NGOs like Sangath that train workers at primary health centres to counsel patients in the community on dementia, depression and schizophrenia.

Rather than just a top down approach, the government needs to encourage and incorporate community level initiatives to help end the stigma and heal.

Time for a Relook at India’s flagship programs

The findings of the Global Burden of Disease 2015 study are truly depressing. The results, published in The Lancet, lists the main factors behind illness, death and disability in countries.

While deaths of children under five years has gone down between 1990-2015 from 12.1 million to 5.8 million, India still tops the number of child deaths at 1.3 million in 2015.

India is followed by Nigeria, which has over seven lakh deaths, and Pakistan with three lakh deaths. Bangladesh has done better. There were 7663 maternal deaths in 2015 in Bangladesh, which is a dramatic improvement from 21,789 in 1990. Maternal deaths in India dropped by half to 63,861 in 2015 from 1,32,239 in 1990

Neonatal mortality, which is death in the first 30 days of life, remains high. While deaths under five years have reduced, it still remains way lower than the MDG goal.

Some of the main causes given in the study are pre-term birth complications, trauma and respiratory infections. Diarrhea-related diseases are the fourth leading cause.

The study says that while government schemes like Janani Suraksha Yojana have been successful in improving access to institutional births, the reach remains patchy with large parts of rural India unable to access the services. This is the demography that remains most vulnerable. A reality we encounter everyday in news reports of pregnant women dying on their way to hospitals.

Clearly, it is time to step back and take a close, hard look at our flagship programs like JSY and the integrated child development scheme, ICDS. The ICDS was launched in 1975 and is one of the world’s oldest nutrition programs. If after 41 years of ICDS, we are still failing so many hundreds of thousands of children, something is clearly going very wrong.


Low contraceptives’ usage, a cause for concern

Despite the range of family planning options made available in India, data from the National Family and Health Survey, NFHS-4, is cause for concern.

The figures released for 14 states shows a fall in the use of contraceptives, compared to the previous NFHS survey done 10 years ago.

With options, awareness, healthcare access and incomes growing, the expectation was that women would exercise more say over their pregnancies, but the data doe not indicate that.

While West Bengal and Meghalaya show an increase in the use of modern contraceptive methods like OCPs and IUDs and a fall in sterilization, the figures for the rest of the state surveyed are not so positive. Over 50% of women prefer female sterilization and there is a decline in the use of contraceptives in some states.

What this means is that a large number of pregnancies continue to be unplanned or unwanted and access to contraceptive methods remains in the hands of a few. In rural areas, women still depend on government health facilities for supply and this is affected by lack of choices, irregular supplies and lack of skilled health providers at the district health centres.

The NFHS data for all the states is as yet not available and therefore a conclusion may be premature. However, the findings from these 14 states, many of which have seen some focused family planning campaigns, is a pointer towards how much more needs to be done.

Ensuring that contraceptive methods are available is a small part of the challenge. Getting women to use them, addressing the myths and empowering them with information about how and when to use these methods is a huge gap which remains unaddressed even in some of the relatively better off states. Tamil Nadu, for instance, shows no change in the use of oral pills. It was 0.20% in NFHS-3 and remains the same in NFHS-4.

Given India’s sizeable youth population and the high prevalence of early marriages, it is critical that resources be invested in making sure that information and access to modern contraceptive methods is made available in rural India.

“There is a need to focus on changing behaviour and the regular, smooth availability of contraceptives”, says Dr Ashok Dyalchand, Director, Institute of Health Management, Pachod. “At the moment, this is lacking”.


Child marriages & impact on mental health

The impact of early marriage on the reproductive health of women has been well documented, but the effect on mental health often gets overlooked. Child brides often find themselves struggling to cope with anxiety and depression and find little sympathy or support in their marital home.

A sociological study done by the University of Calicut among 600 women who had married before the legal age found that most of them were in conflict with their husbands and other members of the marital home. They were under pressure to take over the household chores and produce a child early.

Any assertion of right or voicing an opinion was treated as a challenge and often met with ridicule, even physical abuse.

A new India wide study by the Delhi-based SAMA Resource Group for Women and Health is also examining the wider impact of early marriage on a woman’s health. Early findings of the report say that when girls are forced to leave school and marry, they experience a loss of mobility. The immediate result is a loss of companionship as they are no longer free to meet their friends. This is a major cause for distress.

Every aspect of their lives comes under close watch – from what they wear to whom they speak to – so there is a constant feeling of apprehension that they might break the rules.

Any sign of sadness or unduly quiet behaviour is regarded as proper and hence gets ignored. It is only when the signs of mental health become very obvious that outside help is sought and this is not professional help, but from traditional faith healers.

“Whenever there is physical violence, it shows up in scars”, says Praful Kamble, Program Officer of SNEHA’s Little Sisters program which has been working towards bringing addressing domestic violence issues in Mumbai’s Dharavi area. “But the impact on the mind is 25% more. There is depression and a sense of shock. And when there is negative support from the family, the woman feels even more isolated.”

Geeta (name changed) experienced verbal violence from her in laws and husband, as her son was constantly ill. Even her sisters-in-law did not support her. One day she threw kerosene on herself and set herself on fire.

“I did it out of despair”, she says. “Caring for a sick child was stressful as it is and then to be constantly blamed for it was a miserable feeling. I was worried for my child and had no idea where to seek help.”

There are multiple linkages between early marriage and health. Mental health is a key one, and needs greater focus in India’s programs and policies.


Tacking malnutrition in Mumbai

The latest data put out by the Integrated Child Development Services highlights what a tough challenge tackling child malnutrition in Mumbai’s slums remains.

The latest data says that the slums have over 50,000 moderately underweight and over 3,000 severely underweight children. Undernourished children account for a massive 17% of the total children weighed in anganwadis across Mumbai until March 2016.

All this shows how tough challenge malnutrition remains despite the various interventions, both by the government as well as NGOs.

Between 2015-16, eight children, who were suffering from malnutrition, died. Five were infants below the age of one year, while the rest were between three to six years.

Experts say that the figures highlight the challenges of dealing with a migrant population.

“The slums that have reported such high numbers are home to a migrant population, people who come from different castes and religions”, says Dr Yogesh Nandanwar, Head, Gynecology, at Lokmanya Tilak Municipal Hospital. “The mothers are anemic and undernourished and they are in no condition to have health babies. “

Dr Nandanwar calls anemia the nucleus of all problems. “Because of anemia, worm infestation becomes an issue. Low hemoglobin is another major issue.”

Given that migrants account for one-third of Mumbai’s population, the numbers are enormous. And the fact that this is a floating population makes the challenge even bigger, underlining the need to have a specific policy to look at nutrition issues among the city’s migrant population.

Millions left behind in India’s public health system

Two news reports in the span of 10 days bring home just how grave the crisis in India’s public health care system is.

First was the report from Odisha of a tribal man who had to carry his dead wife’s body on his shoulders for over 10 kilometres because he was denied an ambulance to go back to the village for her final rites.

Then less than a week later came the tragic story from Kanpur of a 12-year-old boy who died after he was denied admission at a government hospital. His father, who was holding the sick child in his arms, was told to go to a children’s hospital despite his obvious poor health. The man’s pleas for transport to carry the boy to the children’s facility were denied.

These are just two instances that we know of because they got media attention. Imagine the thousands, even millions of people across the country, who are unable to access medical treatment on time.

The World Health Organization says the ideal norm is 1 doctor for a population of 1,000. Going by that measure, India falls short by 500,000 doctors as pointed out in a recent IndiaSpend report. Going by these figures, there is one doctor for 1,674 persons, which is worse than Vietnam, Pakistan and Algeria. Even this, many experts believe does not reflect the reality and that the ratio is closer to 1:2,000.

The shortfall is evident not only when it comes to doctors but also support staff like midwives and ASHA workers who form a critical backbone when it comes to rural health care. Under the National Rural Health Mission, more health centres have come up in our villages but there are simply not enough doctors and nurses to man them.

The shortfall gets reflected in the statistics relating to infant and maternal mortality. Despite interventions at various levels, the figures are not improving fast enough. All the plans and policies remain words on paper because there are not enough people on the ground to see them through.

Fighting gender violence together

A recent IndiaSpend report on crimes against women in the Capital brings home the many promises made in the aftermath of the Nirbhaya rape in 2012 that remain unmet; and how four years after that horrific assault on a paramedical student, the number of rapes in Delhi has tripled.

After the incident, the Verma Commission that was entrusted with looking into reforms proposed many changes to the law. Chief among them was hiring more women in the police force as it was seen as a vital step towards ensuring greater sensitivity towards rape survivors. As the IndiaSpend report highlights, this, like along with many others like hiking expenditure on police training remains on paper.

Police, the world over, handle rape badly. Even in developed countries like the US and the UK where resources are so much more advanced, there is a huge variation in the way rape is recorded and how survivors are treated.

In India, where this is compounded by a crippling shortfall of staff, experts say there is a need to take a more pragmatic approach towards tackling crimes against women.

One that does not put the entire onus on the police, but a multi-sectoral approach that involves different agencies across key sectors – health, psychosocial and justice – working together.

Increasing the number of female cops is not the sole answer, says Dr Nayreen Daruwalla, Program Director for Prevention of Violence against Women and Children, SNEHA. “Women share the same concepts of patriarchy and are not able to shed their deep entrenched attitudes while dealing with cases and survivors of violence”, she says. “We are working towards making violence against women and children a public concern, so should not the responsibility of assisting the survivor lie with all duty bearers, irrespective of being a woman or a man?”

Daruwalla argues that a multi-sectoral approach offers a more effective, long-term solution to bringing down crimes against women, pointing towards SNEHA’s convergence approach in the Mahim and Nehru Nagar police stations of Mumbai.

In September 2013, when SNEHA started an observation and in-house training program in gender sensitivity in these two stations there was some initial discomfort. However, gradually there was an understanding from both sides of each other’s pressures and needs.

While the counselors got to witness firsthand the extreme stress and staff crunch the force faces, the police too realized that SNEHA’s presence and inputs were helping them handle cases related to gender based violence in a better manner. It also helped tone down levels of aggression and the use of abusive language. Gradually the police began to reflect upon their patriarchal mindsets.

A study done before and after the program on the policemen who participated showed significant results. Some of them were –

*Greater understanding of the law against domestic violence

*Greater awareness of stalking, violence and disrobing as forms of violence

*53% decrease in the number of policemen who thought it was important to ask if a woman had provoked an act of violence

*Nearly 70% decrease in the number of police who said a woman’s sexual past was not important while recording a rape complaint

The greatest testament to the changes came from the women in the community who said that they were satisfied with how they were being treated by the police in these two stations.

“Changing mindsets is a longer term process that requires regular follow-up and reinforcement”, says Dr Daruwalla. “We work with the premise that the police are ready to fulfill their role appropriately and adequately if given an opportunity to work in a supportive environment. “

The convergence approach pioneered by SNEHA holds many lessons. Enabling the law system to respond to violence against women and children needs a supportive environment, one where various agencies come together and work in partnership with the police.

Instead of seeing the police as the ‘other’, it brings the community closer to the men in uniform, making the fight against gender based violence, everyone’s battle.





Let’s Talk About Periods

She may have missed out on a medal but Chinese swimming star Fu Yuanhui is being hailed as a champion back home and around the world for breaking the taboo that comes attached with periods in sports.

Fu attributed her team’s failure to make it to the top three in the 4x100m medley relay to the fact that she started her periods a day before the event, a remark that the Chinese media was quick to praise, given the silence that surrounds menstruation. Soon athletes and activists around the world picked followed suit.

Across the world, and more so in countries like China and India, there are a deep-rooted cultural resistance, even stigma, attached to periods. There is indignity and even a certain revulsion attached to it, which prevents open discussion. Which makes statements like Fu’s, or American musician Kiran Gandhi who ran the 2015 London Marathon while she had her periods, welcome.

For those who might think them over the top, consider this. Menstruation remains a major barrier to achieving gender equality in many parts of the world today.

Adolescent girls in developing countries miss five days of school in a month due to lack of access to sanitary pads and hygienic toilets in schools. This makes them fall back in education.

Menstruating women in countries like Nepal and India are seen as impure and a sign of bad luck. They are made to sleep outside their homes and eat out of different utensils.

If talking about periods openly and scientifically can help end this damage of a million lives, then by all means let us all start.

We Have the Act. Time to Create the Awareness

The provision of the Maternity Bill extending maternity leave to mothers The provisions of the bill will apply to all organizations that employ 10 or more persons and is expected to benefit over one million women working in the organized sector.

Given the majority that the ruling government enjoys, its passage in the Lok Sabha is guaranteed, after which the Labour Ministry will notify the changes.

As per the amendments, maternity leave for women in the private and public sector will be increased to 26 weeks as against the present 12 weeks. However, those who already have two or more children will get 12 weeks of leave only.

The bill also proposes 12 weeks maternity leave to mothers who have children through surrogates as well as working women who adopt a baby below the age of three months. The Act will also allow nursing mothers to work from home after the 26-week maternity leave ends, depending upon the nature of their job.

However, the real work starts now. While the provisions are a progressive measure, there needs to be awareness created for the benefits of this to come through. The period after birth is critical for both the mother and the child’s health and the root of the amended act lies towards preventing malnutrition. That is the primary purpose of the Act, which is not to be treated as a holiday.

Passing the Act has to go along with creating awareness about breastfeeding and other measures that are to be taken to secure the health of the child and the mother. There needs to be a well thought out policy to promote breastfeeding, which is still lacking in India. Various studies show that less than 25% mothers in India initiate breastfeeding in the first hour after birth.

The WHO says that initiation of breastfeeding within an hour after birth could bring Infant Mortality Rate by as much as 22%. Nearly 77% of child deaths worldwide are attributed to non-exclusive breastfeeding during 0-6 months of life.

Both the WHO and UNICEF recommend breastfeeding within an hour of birth, only breast milk for the first six months, and continued breastfeeding up to the age of two years, along with appropriate complementary food.






New Mental Health Bill is a much welcome step

The Mental Health Care Bill 2013, is welcome as it a step towards acknowledging the huge shortage of infrastructure and psychiatrists in the country. The bill aims to protect and promote the of rights of people with mental illness and offer better support and facilities to people suffering from various types of mental illnesses.

In India, mental health problems are more common than cancer and heart diseases. There is a high prevalence of mental disorders, from 58.2 to 73 per 1000 population.

However, research says that over 80% of people suffering are not getting the required treatment due to shortage of mental health experts, stigma, inadequate facilities and the high treatment costs. At present, there is only one psychiatrist for every 343000 people.

The new Bill is progressive because it acknowledges these glaring shortfalls and also calls for greater support for caregivers who are largely neglected. The move to decriminalize attempted suicides also recognizes the rights of the mentally ill. The focus on compassion and responsibility is also a welcome shift away from socially stigmatizing those who suffer from mental illnesses.

However, how effective this Bill will be depends on the implementation and this is a big question mark. Since health is a state subject, different states are left to their own devices when it comes to bringing the various provisions into force and this could undermine many of its positives.

Time to End the Shame Around Breastfeeding

Last week, protests were witnessed across Argentina by groups of women who breastfed their babies in public. They were agitating against the police’s move to throw out a mother from a square in Buenos Aires for nursing her infant in public.

Carrying signboards that said, “Nursing is not up for discussion” and “My breasts, My rights”, over 500 women took to the streets in different parts of the country demanding respect for mother’s rights.

Breastfeeding is a simple, no-cost intervention that boosts the health of children and women substantially, in rich and poor countries. Yet there is little awareness about this. And as we get set to observe World Breastfeeding Week (August 1-7) around the world, experts are calling for programs that encourage ideal breastfeeding practices.

Studies in The Lancet point out that increasing breastfeeding to optimum levels could save over 800, 000 lives every year, most of them children under six months. Also, nearly half of all diarrheal diseases and one-third of respiratory infections in children in low- and middle-income countries could be prevented.

Babies who get no breast milk at all are seven times more likely to die from infections than those who get some in their first six months.

Children who are breastfed also do better at intelligence tests, are less likely to be overweight and less likely to get diabetes later in life. The benefits to mothers are also huge. They show lower risk of developing breast and ovarian cancers.

The awareness is especially abysmal in low-income countries, like India. And it does not help that the government has not aggressively promoted breastfeeding. The focus on bringing down maternal and child deaths has been heavily directed towards promoting institutional deliveries, antenatal check-ups and neonatal care.

There are many barriers that come in the way of early breastfeeding in India and this helps explain why signs of childhood malnutrition like stunting (45%) and wasting (20%), that depend significantly on early breastfeeding, remain high.

According to studies, only one in four mothers are able to start breastfeeding within one hour of giving birth and less than half of all mothers are able to exclusively breastfeed their babies for the first six months after birth.

Supportive health-care systems, workplace interventions, counseling and educational programs are needed to improve breastfeeding. The government’s recent moves to bring changes to the Maternity Benefit Act of 1961 are welcome steps.

There is also a need to break the wider social shame that exists around breastfeeding in public, something the UN has also acknowledged by backing the social trend of belfies – mothers sharing pictures of themselves breastfeeding. It is a welcome step towards ending that stigma and spreading the word about the importance of a mother’s milk.




No Country for Children

It’s been a damning week for India.

A series of reports from different parts of the country brings home just how poorly our children are doing when it comes to access to basic nutrition, sanitation and health.

First Odisha, where according to official figures, 15 children have died of malnutrition-related illnesses in the tribal Nagada village since January. Village authorities say the actual figure is much higher. The news finally made it to the headlines only when five children died in a span of 20 days.

The children in Nagada and nearby villages all show signs of severe malnutrition. The bad roads’ leading to these villages has meant lack of access to basic health care and clean drinking water. It took several newspaper TV reports for authorities to organize a kitchen and a health camp.

The fact that so many deaths have taken place in a mineral rich region of the state has exposed just hollow Odisha’s development claims are. The several flagship schemes for children of vulnerable tribal groups remain on paper and don’t seem to reach those who most need it.

And then this week we also had the results of a combined study by experts from the Johns Hopkins Bloomberg School of Public Health in the US and School for Applied Studies, Delhi, found that diarrhea kills nine children under the age of five in Uttar Pradesh every hour, which 71, 000 deaths in a year.

The study found that just over 15% of private doctors in UP prescribe zinc, which strengthens the ORS. Even the most basic treatment of childhood diarrhoea is a problem across large parts of the state. This explains the huge numbers as since most families opt for private over public health care.

Again, diarrhea is easily preventable with safe drinking water, sanitation, nutrition, to mention just a few.

Finally this week, we have the most recent WaterAid study that says India has the largest number of stunted children in the world, ranking higher than smaller economies and conflict-ridden countries like Pakistan and Nigeria.

Two in every five children under the age of five years in India are stunted, a condition that affects not just physical growth but emotional and cognitive development.

The report points to sanitation as a major cause, citing the practice of open defecation, which is widespread in India.

A country cannot lay claim to be a global economic superpower when it’s children are dying for lack of access to basic amenities; amenities linked to basic rights enshrined in the Constitution, but remain a mirage nearly 70 years after Independence.


Worrying State of Mumbai’s Health

The NGO Praja Foundation’s latest report raises many, many red flags on the state of health of Mumbai. Despite being the financial capital, Mumbai ranks poorly on many key health indicators.

The number of dengue cases has gone up by nearly 117% from 2011 to 2015 and the number of people dying of dengue has also doubled in the same period. TB continues to be a major threat with the disease claiming 7000 lives a year.

This is despite the fact that the Brihanmumbai Municipal Corporation spends nearly Rs 220 crores every year on public. Clearly there is little to show given the enormous sums spent.

Some of BMC’s initiatives like the fight against malaria are showing results. Malaria figures have stabilized due to the Fight the Bite campaign but a lot more needs to be done to eradicate the disease. Most critical is to look at improving the BMC’s surveillance system. BMC records for 2015 show just 16 malaria deaths. On the other hand, the Public Health Department issued death certificates in 92 cases where the cause of death was malaria. There is a similar discrepancy in TB figures within the BMC departments.

Apart from revamping the surveillance and reporting systems, the report also highlights the need to strengthen the public health system, which is hopelessly inadequate to meet the needs of the city’s population. Most people opt for public hospitals as they are affordable but there is a severe shortage of staff, from doctors to nursing staff.

One of the UN’s sustainable development goals (SDGs) is to end the spread of water-borne and communicable diseases by 2030. It’s a commitment that India too has made. And if this is the state of health in a city that is considered to have the best public health system in India, then the government needs to take a relook at its health priorities.


Strong case for a nationwide “fat tax”

For the first time in India, the Kerala government plans to impose a “fat tax” of 14.5% on branded food chains and restaurants selling food like pizzas, burgers etc.

The announcement has evoked strong reactions.

Some have dismissed it a meaningless move that will not help achieve the stated goal of reducing the consumption of junk food and cutting down obesity-related illnesses. Others have called it yet another excuse to tax the middle and high-income groups.

The argument in favour of such a tax in Kerala is compelling. National Family Health Survey figures show that after Punjab, Kerala has the second highest number of people suffering from obesity.

How far the fat tax will change this scenario, only time will tell. There is no denying, however, that the move has helped focus attention to the growing epidemic of obesity and lifestyle diseases in India.

As the 2016 Global Nutrition Report highlights, the number of overweight or obese people is rising everywhere, leading to a spike in diabetes and other lifestyle-related diseases. One in 12 people worldwide have diabetes while nearly two million are obese or overweight.

Some health experts in Karnataka are calling for the state government to follow Kerala’s move and impose a fat tax as well. But they are asking for the tax to be extended to Indian snacks and foods like puris, bhajiyas and namkeen as well. Experts also say that while the tax can change behaviour by pushing people towards healthier options, tacking obesity calls for a larger behaviour change that can only be achieved through greater awareness of nutrition and healthy routines.


Pregnancy prevention is still a woman’s problem

An RTI report has uncovered that a total of 26 women died while undergoing sterilization in Mumbai over the past five years, ten in 2015 alone. They went through a tubectomy, which has been the mainstay of India’s family planning program since Independence, a method that the government has promoted as safe, reliable and effective.

Yet time and time again, come reminders like this one of how perilous the procedure can be, especially when the women have persistent and deep-rooted health problems. The most heartrending was the aftermath of a government sterilization camp in Bilaspur, Chhatisgarh in 2014. Thirteen women died and over 120 left with serious health problems after the procedures were botched up due to poisonous medicines and medical negligence.

Be it a rural health camp or a thriving metropolis like Mumbai which reportedly has better access to healthcare, the point is that female sterilization is fraught with risk and there has to be a move away from pushing this. Since April this year, the Ministry of Health has finally introduced the much talked about basket of choices in family planning methods across district hospitals, an acknowledgement that a move away from female sterilization is long overdue.

However, making those choices available is a challenge, especially in rural areas. Making sure that stocks of contraceptives are made available at hospitals and primary health centres is just one part of the challenge. Creating awareness and counseling is also an important aspect.

These are demands that cannot be met adequately given the huge shortage of health workers and doctors across urban and rural areas. The main reason why sterilization continues to be used so widely is because it is a gunshot intervention. It requires no follow up, any check ups or counseling over a period of time, which makes it a popular choice with the medical staff.

The same BMC data for Mumbai also tells an interesting story. Between April 2015 to March 2016, 18,910 women in Mumbai underwent a tubectomy, as opposed to just 810 men who opted for vasectomies in the same period. This is despite considerable evidence that vasectomies are less invasive and require less post surgery care.

All this points to how women are so disempowered when it comes to childbirth. She has no say on when, or how many children to have; yet when it comes to preventing a pregnancy, it remains entirely her problem.

“Vasectomy and safe family planning methods need to be aggressively promoted if we care about women’s health”, says Dr Vijaya Sherbet, a gynecologist at Bengaluru’s Columbia Asia Hospital. “That sense of empathy, of political will has been largely missing.”

Signs of a change are evident. Tubectomy rates are down and doctors at government hospitals are promoting alternate FP methods. But this is in Mumbai, the financial capital. Rural India, or even the outskirts of Mumbai city offer an entirely new set of challenges.



Why are so many children dying in India?

Around 1.2 million children under five years died due to reasons that were entirely preventable according to the latest Unicef report released today.

The report says that most of the deaths were due to diseases that could have been treated and that India is among five countries that account for half of the nearly six million under-five deaths reported worldwide in 2015.

The other four countries are Democratic Republic of Congo, Ethiopia, Nigeria, and Pakistan – all of which have economies much smaller when compared to India’s.

The biggest killers In India are premature and neonatal birth complications, followed by pneumonia, diarrhea and sepsis.

What is disturbing is that two of the countries in the list, India and Nigeria, are on the fast track of growth economically, but are poor performers when it comes to reducing child mortality.

While India’s under-five mortality rate has improved to 48 per 1000 deaths from 126 deaths in 1990, there is a lot left to do.

Even Nepal and Bangladesh have a better under-five mortality rate compared to India.

Diseases like diarrhea can be prevented if sanitation measures are improved. As the Unicef report says, while 94% of India’s population has access to clean drinking water, toilet facilities are available to just 40%.

There is also a need to relook at how schemes like ICDS are performing on the ground to address the loopholes that come in the way of bringing down child deaths. In many states, the functioning of anganwadis has been crippled due to the lack of resources, staff and theft. This is true not just for remote villages but even areas in suburban Mumbai.

While worldwide, under-five mortality rate has come down dramatically, there is need to focus on those who slipping the net. Unless that is done we are looking at 69 million children dying of preventable causes by 2030, many of them in India.

An app that is saving women’s lives in Dharavi

One of the most positive fallouts of the rapid mobile phone penetration in India has been the impact on education and health in rural India. These are parts of the country that have been left out of the benefits of the economic boom and progress seen in urban parts, either due to poor infrastructure or lack of political will. Be it apps that provide health updates or learning tips, start ups are coming up with creative, innovative ways to reach a constituency that was regarded as difficult to access for the longest time.

One such initiative that has received much attention, and for the right reasons, is SNEHA’s Little Sister project that deals with the sensitive subject of domestic violence. DV is rampant in India but has never been given the attention it needs given the scale as most women do not report it. Many of them don’t even see it as an issue as a nationwide survey in 2013 found out. Over 50% of women said it was justified on many counts.

Apart from being a human rights issue, DV is also a health issue. It impacts women’s health in a myriad ways – from causing Post Traumatic Stress Disorder to depression and even affecting maternal health outcomes. Also think of the impact on a child who watches his mother get verbally abused or physically beaten up? You are looking at a generation that will grow up to be either abusers or victims of abuse.

SNEHA’s Little Sister app works by offering women in Dharavi a safe space to seek help. It is private, non intrusive and effective. Most victims of DV are not looking to walk out when they seek help. Often they want a shoulder to cry on before deciding what to do next. Little Sister does just that. It allows the woman to set the pace. Its the comfort of reaching out to someone who you do not have to see again if you don’t wish to and who will not judge you, or your situation.

To find out more about the Little Sister project click here. There is a video link about the project as well. 




Telangana polio scare indicates flaws in immunization program

This week Telangana declared a global health emergency after an active strain of a polio virus, but one derived from a vaccine, was detected in water collected from a drain in Hyderabad. Two lakh vaccines from Geneva were flown in to vaccinate children in Hyderabad as a preventive measure.

The scare is unlikely to make a dent on India’s claim to be polio-free since 2011 as this is not a direct case of polio.The strain found is from the oral polio vaccine, which contains a small amount of the weakened virus that stays in the child’s intestine and helps develop immunity. India can justifiably feel proud of its campaign to end polio, which was a long and tough battle to win.

However, there are concerns about the larger immunization program, as a recent study by the University of Michigan has found. The study says that two thirds of children under five years of age in India had not been vaccinated at all, or had not received the dose prescribed on time.

Every year, in India, over 1.5 million children die due to diseases that can be prevented by vaccines. While the Universal Immunization Program has helped reduce the numbers substantially from the figure of 120 in the nineties, the current figure of 48 is still high. And one possible explanation could be that vaccines are not being given on time.

Experts say that typically a child’s natural immunity after birth starts falling by the time it is  nine months old and it is critical to administer crucial vaccines like measles and rota virus in this period. Delaying this even by a few weeks, not only makes the child vulnerable to the disease, but also other infants in his or her proximity.

Ignorance among new mothers and poverty are major factors for the delay as is the lack of immunization records. Issues that initiatives like mMitra and Immunize India are attempting to address by taking rising on the mobile technology spread across India. Initial results from these initiatives show a lot of promise and given the many challenges of providing healthcare to a country as vast as India, technology innovations like these show the way forward.

Global Nutrition Report paints a dismal picture of India

The Global Nutrition Report, is the annual report card on the the world’s nutrition levels, and documents how every country is doing in its efforts to improve it. It looks at how each country is going about meeting the targets established as well as the steps taken that have proved to be effective in fighting malnutrition.

Nutrition is key to meeting all the 17 sustainable development goals (SDGs) and having a population that is stunted or undernourished can have a crippling effect on a country’s economic progress and social development.

Which makes the 2016 Report a major cause for concern for India. It says India is way off the mark when it comes to meeting the targets set for reducing stunting,  anemia and diabetes. India stands at 114 for under-5 stunting out of 132 countries, 120 out of 1320 countries for under-5 wasting and 170 out of 185 countries for anaemia. The report says that India needs to increase expenditure on nutrition by $700 million if it wants to meet targets.

Not all the news coming from India is bad. Breastfeeding rates are up and India has reduced child malnutrition rates considerably. Stunting, which is linked to frequent infections and insufficient nutrition intake, is also falling at twice the rate it was 10 years ago. but the reports are disparate across the country. Uttar Pradesh and Bihar have made the least progress when it comes to stunting.

Another factor for concern in the report is the rise in diabetes and overweight conditions among adults, which are also indicators of malnutrition. What is lacking is a national strategy that aims at combating all the indicators of malnutrition.

Experts say India’s stunting problem stands for the largest loss of human potential in any country and the crisis is growing with under-nutrition coexisting with over-nutrition and the rise of non-communicable diseases.

Curbing risk behaviors among youth will help prevent spread of NCDs

Creating healthy behaviors among the young is key to tackling a range of non-communicable diseases like cancer, diabetes, cardiovascular issues and respiratory illnesses, according to a new report by the Washington DC-based think tank Population Reference Bureau.

Noncommunicable diseases, or NCDs, are the leading causes of death worldwide, and are among the top public health challenges. Unless action is taken, the deaths due to NCDs are likely to rise to 52 million by 2030. Asia accounts for 54% of deaths due to NCDs.

The report says that 25-29% of India’s population between the ages of 30-70 years is at risk of premature death due to the four main NCDs.

“Adolescence, or young adulthood”, says the report, “is typically when the four main CD risk factors are initiated and established…and the risks are growing, setting them up for poor adulthood. “

Given the critical role that the young play towards a country’s economic stability and prosperity, it is essential to look at investing in their health as a urgent priority. The PRB report cites data to show how NCDs already account for about 40% of all hospital stays and 35% of outpatient visits in India.

Broad policy level intervenions are needed if this is to change. Some welcome moves have been the recent legislation to introduce broader warnings on ciigarette packets and awareness campaigns against smoking. So is the ban on sale of tobacco products near schools and hospitals. But this needs stronger enforcement to be effective.

Also required is the push to create spaces where children can play or engage in physical games, a lack most noticeable in our cities where there ae no safe, public spaces for boys and girls to play games. Many Asian cities have taken steps in this regard. Beijing and Singapore, for instance, have streets with dedicated bicycle lanes, while South Korea and Japan have parks and playgrounds with gym equipment for both youngsters and odler adults.

Its time that India too focused on effective social and behavior change interventions at the school and community level to make sure the young stay healthy, active and avoid risk-free behaviors.

Not enough in this budget for Family Planning

Among the most widely reported statements at the International Conference on Family Planning held in Indonesia in January this year was that of the Indian Health Minister JP Nadda who said that the country was committed to meeting the FP2020 goal of providing 48 million additional women and girls with access to modern contraceptives by 2020.

A global partnership, Family Planning 2020, works with governments, civil society and the private sector to enable women and girls to make decisions regarding if, when, and how many children they want.

The Indian Health Ministry team also announced that women would have access to better quality family planning services. A promise that is being met with. Since April, injectable contraceptives and pills are being supplied to all district hospitals across the country.

However, the recent report by the Population Foundation of India points out just how distant that goal of recahing 48 million women and girls is.

While the provision for health in 2016 has grown by 22% over 2015, with FP seeing a substantial increase of 67% compared to previous years, health remains hugely underfunded in India. The rise this year, it points out, is insufficient to compensate for the whopping 54% decline in allocations to family welfare between 2013-14 and 2015-16.

Meeting the 48 million number needs more than simply expanding the basket of choices. It needs awareness campaigns and better rural health facilities to ensure that babies and mothers survive. Campaigns have to be tailored to meet the specific challenges that a country as varied as India throws up.

While the shift away from female sterilization is welcome, there seems to be widespread official myopia in acknowledging just how deep the links between family planning and broader development goals go, and this is disturbing.

Guttmacher Report underlines need to meet adolescents’ contraceptive needs

Twenty three million – that’s the number of adolescents at risk of unintended pregnancies in the developing countries.

The statistic, part of the Guttmacher Institute’s May report Adding It Up: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents, again points out the huge gap in contraceptive services among adolescent women. The report says that many women who want to delay childbearing are not getting the services they need.

About 40 million of the over 250 million adolescent women between 15–19 years in developing regions are sexually active and want to avoid pregnancy, yet 23 million of them have an unmet need for modern contraception. Most adolescents with unmet need are using no contraceptive method while the rest depend on traditional methods, which have been proven to be not so effective.

All this underlines the need to make sure modern contraceptives is made available in developing countries. This, according to the report, will not only prevent unintended pregnancies but also prevent the 3,000 adolescent maternal deaths reported every year in developing countries.

At 21% India has among the highest unmet needs for contraception in the world. This is despite the fact that we were the first country in the world to launch a government-backed family planning program. However, today countries like Bangladesh and Indonesia, which started their programs much after India, are faring much better.

The government has recently launched a wider pool of contraceptive choices for women. Welcome steps, but there needs to be more focus on behaviour change communication. Young women and couples want to plan their families but do not know where to get the information.

Making girls count: Why open data matters in gender development

“Closing the gender gap is not possible without closing the data gap.” – Melinda Gates

One of the key announcements to emerge from the ongoing Women Deliver 2016 at Copenhagen is the launch of a new data and research partnership to monitor and drive progress on gender targets outlined in the Sustainable Development Goals.

Key to meeting these new gender targets is reliable and up to date information on women and girls to help ensure transparency, accountability and citizen engagement. In most countries, this data is largely missing or incomplete, be it on child marriages, dowry deaths, domestic violence, the wages women are paid, or why and how many girls are dropping out of schools. Having the data helps set concrete plans and goals and hold governments accountable.

This is especially critical in these times given the global financial crisis, natural disasters and widespread political instability. Take climate change related disasters for instance. There is evidence to show that every such crisis affects men and women differently. This is especially the case in developing countries where women face greater risks to life and health due to social structures. However the lack of adequate data to support this differentiated impact means they don’t get taken into account at the policy level.

“Making all girls visible in statistics is a critical first step towards holding governments to account and implementing the girl-focused global goals”, believes Anne-Birgitte Albrectsen. CEO of Plan International, which is one of the groups leading the joint research initiative. Progress on gender equality goals are slow because there are no numbers to track it. “We do not adequately measure the number of girls who leave school due to marriage, pregnancy, or sexual violence, simply the number in school. Millions of girls are left invisible”, adds Albrectsen.

This invisibility supports the attitude that girls and women simply do not count. Having hard numbers for where they live, what they go through and what they want will help bring down that wall.


High time India invests in its demographic dividend

The Lancet Commission on Adolescent Health and Well-being report launched in London on Tuesday highlights just how fragile the state of India’s demographic dividend is.

The report says that suicides are the leading cause of death among people in the 10-24 years category, with nearly 63,000 deaths reported in 2013 alone.

This is one-third of India’s population that we are talking about – a group that many take pride in as a demographic dividend. Clearly, it is crying out for help.

We don’t need to look too far for the red flags. Newspapers, of late, have been flooded with reports of the spate of student suicides in Kota. Since 2015, 26 youngsters, boys and girls, have killed themselves, either because they cannot cope with the burden of studies or feel pushed into career choices by parents.

The district collector has written to the parents of the over 1.5 lakh students living here asking them not to place the burden of their expectations on their kids.

The study author has said the findings should be a “wake up call for new investment in the largest generation of adolescents in the world’s history.” Because this is an age group that is seen as the healthiest, it also has the poorest health-care coverage amongst any age group.

The warning signs are especially strong when it comes to mental health. The report says that in India over 28 lakh youth have suffered health losses due to depressive disorders, an aspect that is particularly neglected.

Suicides due to academic pressure or employment concerns are a major part of the problem, one that the government needs to address by creating more job opportunities.

Equally important is the need to find ways to equip our youth emotionally. Adolescents today face challenges on many fronts and there is a need to acknowledge this and work towards finding a solution to this tragic ending of so many young lives.


Maternal deaths in Mumbai down but there are areas of concern


The recent data released by the Brihanmumbai Municipal Corporation showing a drop in maternal deaths in Mumbai is good news. According to the report, maternal deaths in the city fell to 311 in 2015-16. This is welcome given that the figures on this front have seen a steady rise over the last few decades, except for 2013-14.

One of the main factors is that anaemia, which has been the single largest contributor to the high maternal deaths, has seen a major fall. According to the report, anaemia is behind less than 2% of the maternal deaths in 2015-16. Until a few years ago the figure was as high as 25%. This shows that interventions by the BMC alongwith various organizations like SNEHA in slums have paid off. There is greater awareness about the importance of taking folic acid tablets, calcium and iron from the early stages of pregnancy.

As women I spoke to in Dharavi point out, they would rarely remember to take these supplements during pregnancy. And even when they did, they had no idea how to. They would simply club them together.

“Now I am aware that I have to space them out through the day so they are effective,” says Vandana, who is pregnant with her second child. “These are things that I learned from counselors who visit the area”.

Another positive is that the fight against tuberculosis is showing results. It contributed to 6% of maternal deaths in 2015-16 compared to 11% in 2015-16. Proof that DOT centres in the slums and awareness campaigns by the BMC is paying off.

However, what is worrying is the threat posed by poor sanitation and hygiene. The BMC data shows that a majority of maternal deaths are due to hepatitis – both A and E. Both strains are directly attributed to poor hygiene and the lack of clean water. Around 14% of the deaths in 2015-16 were due to hepatitis.

Experts say the figures highlights the lack of clean water in the slums, Most of the slums, especially in the tertiary areas like Govandi, rely on water from tankers. Lack of safe water is a major risk factor during and post pregnancy.

Apart from ensuring clean water supply, there is also a need to strongly promote better hygiene and sanitation practices like boiling water, washing hands and using public toilets to reduce infections. The solutions are many and entirely in our hands. Like the fight against anaemia, this too is a battle that can be won.


Water crisis has links to women’s rights & economic progress

Just how grave the water shortage in India is brought out in IndiaSpend’s latest report, which says that India is facing the worst crisis in a decade, with the shortage likely to create drought-like conditions in many parts of the country.

We are already seeing the worst of it in many regions. Farmers in Bengaluru led a protest over water scarcity that lasted days. The water crisis in Karnataka is affecting Tamil Nadu and Andhra Pradesh, which are among the states that will be worst hit this year.

The impact of this scarcity will be felt most by women and children, especially girls, on every count, be it health, education or nutrition.

In Bundelkhand, Uttar Pradesh, the acute drought has led to an alarming drop in nutrition levels. 86% homes have cut down on dal intake, while 84% have cut down on milk for their children.

The threat of food scarcity is not limited to Uttar Pradesh alone given that there is not enough water to irrigate farmlands. So we are looking at a potential food shortage across the country.

Clean water affects education. It helps keeps children in schools. This is especially true of girls because in rural India, the task of fetching water still remains the primary responsibility of women. Families in Marathwada, in rural Maharashtra, which is facing severe water scarcity, are pulling their children out of school so they can help fetch water.

Perhaps the biggest concern is the impact on health. The acute shortage of safe, drinking water will lead to a spiralling of diseases like diarrhoea. There are over 300,000 diarrhoea-related deaths in the world every year. 45% of them are from India.

Access to clean water is not just a supply and demand issue. It has links to women’s rights, maternal and infant health and overall economic progress. Its time we looked at water from a larger perspective rather than battling it from season to season.


Quiltessentially SNEHA – Threads that bind and empower

As you walk into the exhibition of Quiltessentially SNEHA, the thought that strikes you is how the sea of rich patterns and intricate weaves is such a powerful expression of SNEHA’s work; conveying both the range of its outreach work and the ties it builds in the communities it works in.

Quiltessentially SNEHA, the livelihood project started in 2009 by the Society for Nutrition, Education and Health Action, aims to equip women in slums with various skills that will strengthen them financially

“I was supervising a tailoring class for adolescent girls and women and that’s when the idea came about. We thought why not start a small unit that makes patchwork quilts”, says Naina Fernandez, project director.

Naina Fernandez, Project Director & Seema Singh, Volunteer

Initially she relied on fabrics donated by clothing and furnishing stores that usually have large swatches left over.

“We taught the women basic stitching skills and we had some sewing machines and we were set to start”, she says.

The women would put the pieces together guided by creative inputs from Fernandez.

This is how it all started, with patchwork quilts

Some families took a little convincing at the start.

“There was this young girl who was really talented but in the early stages, the earnings weren’t that good”, says Fernandez. “Her family pulled her out because they felt she was better off working as a domestic help. I stepped in and insisted that she had a gift and they should not stop her from coming to the center”.

From quilts, the range of products has expanded way beyond to dupattas, bathroom mats, bedspreads and cushion covers. And then there are the small and thoughtful items like pouches for sanitary pads, an idea that Fernandez says came from school-going adolescent girls that SNEHA works with.

Pouches for sanitary pads

The designs are never repeated so each product is unique. The demand for the products is huge, especially among corporate houses.

The project employs about 40 girls and women, with 13-15 working on a shift basis. The timings are flexible as many have young children or elderly in-laws to look after. On an average, each person earns upwards of Rs 5000 a month.

Income that Manali, one of the earliest members, says comes in handy, especially when finances run low.

“My husband is a BEST driver and he earns decently but we used to feel the pinch when my children needed books or clothes. Now I contribute and ease the financial burden which makes me feel great”, says Manali. “I am able to support my family”.

Manali (right), among the early members

Above all, the project offers a safe space for women to get together and bond over shared experiences and issues.

“We stitch together, we share, laugh, chat, give each other advice and in the process feel lighter”, says one of the project members.


“I can often hear them giggling loudly as they work” laughs Fernandez. “People in the nearby units tell me these people make such a racket. So I know they are in a happy space.”



How Climate Change Impacts Women More

Amidst the stream of news reports on the severe drought across India, here is one that didn’t make it to primetime.

It’s the story of Yogita Ashok Desai from Maharashtra’s Beed district who died of a heat stroke. The 12-year-old was dehydrated and collapsed after her fifth trip to the village hand-pump to fetch water. Just last month,  a 10-year-old girl from Pimpalgaon village, also in Beed district, died after she fell into a well while trying to draw water.Both girls had been pulled out of school to help their families cope with the severe water scarcity.

The reasons for the worsening drought are many; many of them manmade like the indiscriminate digging of borewells and the cultivation of water guzzling crops. Decisions that women had little to do with. excluded as they are from choices relating to irrigation systems or what crops to grow. However, they are facing the worst impact.

A recent World Bank report, Shock Waves – Managing the Impacts of Climate Change on Poverty, highlights how ending poverty and addressing climate change is key to achieving sustainable global development. Addressing climate change is critical as it directly impacts availability of food and heightens health risks.

Most vulnerable are the poor and marginalized, and within that group, women and children. There are various studies that show that women, especially in developing countries like India, suffer the impacts of natural disasters and climate change more due to cultural norms.

In rural areas, women rarely work and are economically dependent on their husbands for survival. Faced with a severe drought, men have the resources and the independence to find ways to adapt. Women are denied those options.

Faced with a shortage of food, women place their husbands’ and sons’ needs above theirs or their daughters’, making them vulnerable to diseases.

Faced with income or food crunch, girls’ get hit the hardest. They get pulled out of school and are expected to help with the household chores. Their nutrition and health gets neglected. Climate change also affects availability of water. Women and girls’ are expected to fetch water for the family, often traveling long distances to do so.

As Rachel Yavinsky points out in her 2012 study, their secondary role and lack of decision-making power severely limits women’s ability to adapt to climate change.

“Without participation by women, programs to replace traditional crops with those better suited to the changing environment might focus only on the needs of men’s fields and not address the problems women face with household gardens’, says Yavinsky.

She points to various studies that demonstrate how women can be effective agents of adapting to climate change if equipped with information and power. In Bangladesh, for instance, women farmers switched to raising ducks because they kept losing their chickens to frequent floods.

Empowering women, especially rural women, is necessary to address climate change effectively. Climate change will affect all os us, most of all women, and unless we empower them, building a sustainable future will remain a distant dream.