Largely thanks to recent news reports, Jharkhand's West Singhbhum district conjures up certain images in the mind — Naxalite-dominated, tribal-populated, mineral-rich … From distant and urbane Delhi, it sounds like the badlands.
A three-hour drive from Ranchi to Chakradharpur town, or “CKP” as it is known in the district, presents an entirely different picture. A tranquil and lush green landscape reveals itself along a seemingly endless natural tunnel formed by sal and banyan trees that flank an undulating and windy road. No other car or person is visible for a mile at a stretch sometimes. Barring the occasional slowdowns at security checkpoints manned by personnel in khaki uniforms, there is no visible sense that what has been termed India's “gravest internal security threat” may be inches away, in the woods.
It is to counter a different, more visible internal national threat, though, that West Singhbhum and its neighbouring districts have been positively cited in leading international publications of late. Between 2005 and 2008, as many as 193 villages in West Singhbhum and Saraikela districts in Jharkhand and Keonjhar in Orissa witnessed a 45 per cent reduction in newborn mortality, a 20 per cent reduction in maternal mortality and a 57 per cent reduction in post-partum depression.
The reductions are all the more striking because they have occurred against the backdrop of two States that have routinely recorded some of the highest infant and maternal mortality rates in the country. Along with Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Assam, Andhra Pradesh and Chhattisgarh, the States of Orissa and Jharkhand account for a lion's share of the approximately million infant deaths and 80,000 maternal deaths that occur annually in India.
An NGO's success story
Behind these striking achievements is the work of Ekjut, a non-governmental organisation run by the husband-and-wife doctor duo of Prasanta Tripathy and Nirmala Nair. Lean-built and enthusiastic, and with a salt-and-pepper moustache, Dr. Tripathi could at first glance be taken for an Army officer.
“The way I look at it, it's just no age to die,” he said, explaining his motivation. “This work is also about paying it forward for future generations.”
Dr. Nair is his quieter half, but with a resolute air about her. Both of them spent a substantial chunk of their early careers at Tata Steel, India's largest producer of steel. The company set a high standard of corporate social responsibility (CSR) in earlier years but has increasingly come under fire for its role in environmental degradation and the displacement of some of the very same marginalised, tribal communities that Ekjut serves. “We knew even back then that someday we'll work closely with communities,” says Dr. Nair, who worked in the Tata Steel hospital in Jharkhand's mining town of Normundai. Dr. Tripathi had meanwhile helped shape and implement the company's CSR initiatives.
Functioning in partnership with the Institute of Child Health, University College London, Ekjut received funding from the Health Foundation. It cost an estimated $33 per daily-adjusted life year (DALY) saved, compared with the World Bank standard of $127. It was less for interventions to reduce child mortality. On April 3, 2010, The Lancet (Volume 375, Issue 9721), the rigorously peer-reviewed medical journal, featured a lengthy article on the “Ekjut trial”— as it has come to be known. The same publication recently ran a report titled “The Countdown to 2015: Maternal, Newborn and Child Survival,” in which India's performance in curbing infant mortality was marked “insufficient,” and its maternal mortality level was classified as “high.”
Ekjut's main approach seems dumbfoundingly simple — to piggy-back on the network of women's self-help savings groups in order to discuss child and maternal health issues. On closer scrutiny it becomes clear that a triad of strong guiding principles has played a critical role in the success: community mobilisation, participatory learning and empowerment.
At the crack of dawn, about a dozen women belonging to the Ho tribal community gathered outside one of the mud houses in their village in Chakradharpur. Seated on a large jute mat, about half of them held infants in their arms. Chicks and hens fluttered about. Many more babies lay naked on the mat. Younger children playing about crawled in, too. Two facilitators called the meeting to order and rolled out a chart with photos stuck on. As the meeting wore on, infants intermittently clung to their mother's breasts.
By the end of it, little piles of tamarind seeds had formed in front of each picture on the chart. “These tell us the type of problems that women face in the village,” said Sumitra, a straight-talking, star Ekjut employee. She is from the Ho community. “The more seeds the women pile up in front of a picture, it means the more common that problem is in that village,” she said. “Then we customise our work for each problem.”
Tamarind seeds in front of picture charts form just one example from a single meeting. As the cycle progresses, a series of meetings take place regularly across all the districts where Ekjut is at work. Now there are six such districts in Jharkhand and three in Orissa. The communication tools get more innovative and the meetings more participatory. They employ visual cards, dummy dolls, storytelling, role play, street theatre, dancing and singing and a lot of talking in between. The result is behaviour change that is hard to see and easier to measure, as Ekjut's painstaking data collection and analysis demonstrated. Still, some before-after patterns are discernible.
Junga Saman (30) has mothered eight children, of which three died of unknown causes. “In my village, when you've a baby you're considered dirty,” she said. “The baby is not breast-fed for days. Both are kept away from everyone in the house. Often, the mother only gets to eat bread with salt and garlic. Earlier, when a problem arose, we would pray. Now, I go to a doctor at the slightest problem. I ate spinach, fish and vegetables during and after my recent pregnancy. I breast-fed for six months from the first day.”
Geeta Tiu (32), mother of four, has been attending Ekjut meetings for five years. “Earlier, we didn't clean our hands before cooking and eating,” she said. “We'd just leave the baby and go off to work. Now we clean and grow vegetables ourselves. We keep the water clean in the house. Women in the village help one another and sometimes pool money to transport someone to hospital for delivery and visits to the doctor.”
Shanti Shandal (25), who has two girls, lost a baby during her first pregnancy. She had a retained placenta, which a midwife took out by hand — medically speaking a strict ‘no.' She said: “The baby was born weak and just lay in the cold for and cried all night. I didn't know at the time that I should go to the hospital. He died the next day. In later pregnancies, I went to the anganwadi and took vaccinations and iron tablets, too.”
Government health officials typically cite challenging terrain, poor infrastructure and “disturbed areas” as reasons for poor performance in a range of development efforts. If there is anything the Ekjut trial shows convincingly, it is that while these conditions can pose genuine hindrances, they can be overcome with strong political and human will, commitment, investments and rigorous monitoring and follow-up. This is underscored by the Ekjut trial's most telling outcome — the poorest and most marginalised people benefited the most. There was 73 per cent reduction here in newborn mortality as compared to 36 per cent for the general population.
“This was not by design,” says Dr. Tripathi. “But it shows that if the project design is robust, the poorest will automatically benefit the most.”
As for the threat from the woods, the State-level Director of the National Rural Health Mission, Aradhana Patnaik, said: “Health and education have never been targeted by Naxalites in Jharkhand.”
( Divya Gupta is an independent journalist supported by Save the Children to raise awareness about issues around child mortality, ahead of the U.N. Millennium Development Goals summit to be held in New York from September 20 to 22 .)