Johns Hopkins Magazine - February 1995 Issue

Stories of Survival

By Melissa Hendricks

When it comes to saving the children of developing nations from preventable illness and death, strategies vary widely -- from teaching women to raise and sell rabbits, to holding health clinics beneath a tree.

Jehu Vasave smooths the folds of her blue sari, sits forward on a hard chair, and begins a melancholy song for me in Mauchi, a western Indian tribal language.

When a lady gets pregnant she should go regularly for checkups. In the first three months don't stop eating, even if it's just bread mixed with rice. Between the fourth and seventh month, get two injections of tetanus toxoid. If you eat meat, eat a lot and mix it with tomatoes and beans.

We're sitting in a corner of a hotel lobby in Bangalore, India, the site of an international conference on child survival, and we're both experiencing culture shock. I'm reeling from a 36-hour trip that's landed me far from Maryland, geographically and in every other way. Vasave is dazed because she just flew on a plane for the first time, having rarely before left her native Nawapur, a region of tribal villages to the north. She just spent the day listening to speeches in English, which she doesn't understand. But she welcomes an opportunity to tell me, as someone translates, how songs about immunization, diarrhea, and AIDS are saving children's lives.

A middle-aged woman with toughened hands and sad eyes that hint at a life of taxing work, she belongs to a cadre of health workers from Nawapur who were trained by the private voluntary organization World Vision to teach local women about children's health. Since 60 percent of the women in Nawapur are illiterate, she explains, they aren't helped by books and pamphlets. "But they sing beautifully." They sing songs about health while rocking their babies to sleep.

Providing health information to people who can't read is one of the myriad roadblocks confronting private voluntary organizations (PVOs) such as World Vision. How do you conduct a child health program in Haiti during a civil war? Is there a way to vaccinate children whose parents believe measles is the will of a goddess? How do you help malnourished children and assure that they won't go hungry again after you leave?

World Vision participates in a much larger endeavor, a PVO grant program operated by the Johns Hopkins School of Public Health. The grants are awarded by the Agency for International Development (A.I.D.), and go to PVOs like World Vision, CARE, and Save the Children. Over the past 10 years, the School of Public Health's Child Survival Support Program has managed 199 grants, with funds held constant at $15 million each year. The 15-member Hopkins team "brokers" the deal, says the program's coordinator Dory Storms (ScD '82). In addition to selecting grant recipients, Storms's staff also trains PVO workers.

Historically, says Storms, the strength of PVOs lay in identifying people most in need of help--the disenfranchised in the hardest to reach spots, people in the poorest slums, refugees--and getting resources to them. That's still the case. But now the PVOs involved in the Hopkins program are required to do something else: be rigorously accountable for every penny. PVOs must specify precisely the money spent per resident within a community, the number of mothers they've educated, children they've vaccinated, or lives they've saved. "Now 'the bottom line' is what matters," says Storms. "The Hopkins program is results-oriented. If you're not getting the results, do something else."

As the child survival program neared its decade mark, representatives of A.I.D., Hopkins and PVOs from 16 nations met in early October, at a conference center on the outskirts of Bangalore, in Karnataka State, India. They came to this southwestern corner of India to show how they have helped more children in the world's poorest communities to live.

A few weeks before the conference began, pneumonic plague struck to the north of Bangalore, in Surat. As the conference proceeded, a dozen cases were reported in Bangalore. Most people who had planned to attend were not stopped by the plague, though some had to zigzag from one country to the next to find an unrestricted route into the quarantined land. The nearby plague only reinforces the need for work like theirs, which helps to control infectious diseases that rage in areas of poverty and inadequate healthcare.

The program's directors had invited me to attend the weeklong conference to hear the story of the child survival program. So, stoked with enough prophylactic medicines to kill an army of vermin, I boarded a plane in Baltimore, and 36 hours later arrived in Bangalore.

As the meetings began, I quickly learned that the projects overall have cut the mortality rate for children at project sites in half, according to one estimate, at an average cost of $1.92 per person served. But conference leaders also acknowledged the overwhelming problems that remain. As of 1992 , the mortality rate for children under age five was still nine times greater in the developing world than in industrialized nations. Illnesses like measles and pneumonia are still everyday concerns, claiming 1 million and 3 million children under age 5, respectively, each year. Many of those deaths are preventable. AIDS is a new killer, while certain old diseases are more deadly than ever: respiratory infections and malaria. As the 70 conference participants marked their successes, they also looked ahead to see what more can be done.

What works in one country won't necessarily work in the next, or in the same country from year to year. But what is emerging is a basic program--a sort of recipe--for child survival. The central ingredient? Don't go it alone: Local communities, governments, organizations, and people like Vasave must be involved so that accomplishments last once the PVO packs up and leaves.

Sing a song of immunization

In the hotel lobby, Vasave continues her repertoire of songs. "How about a song about AIDS?" she asks. "Diarrhea?"

"That's okay," I tell her. I'm more anxious to hear about what she does as a community health worker.

She laughs, and shakes her head in a movement in between a no and a yes--the Indian way of saying "yes."

Before becoming a health worker, she says, she was an ordinary villager, ignorant of modern health care. World Vision then trained her to make housecalls and provide health information through women's clubs called Mahila Mandals. Now, she says, "I represent women whose lives have been changed by child survival programs."

Vasave and other health workers trained through PVO grants emphasize preventive health care.The idea, Hopkins's Dory Storms told me earlier, "is to train a woman so that she becomes the front-porch mom, and educates others." Lessons spring from four "magic bullets" of public health: Growth monitoring of children, Oral rehydration therapy, Breastfeeding, and Immunization (GOBI). In 1984, UNICEF announced that these four simple interventions could dramatically reduce the death toll of children. According to PVO leaders at the conference, however, GOBI is only a start. Today's child survival programs involve much more, including new types of magic bullets, education programs, and economic development schemes.

In the homes she visits, Vasave explains, she teaches women how to prepare oral rehydration solutions. She weighs children, helps arrange for itinerant nurses to come give vaccinations, and answers questions. Many women ask about which weaning foods to give their children and about family planning, she says. Since Nawapur is only 110 kilometers northwest of Surat, the city recently stricken by plague, this fall Vasave was also giving precautionary dosages of antibiotics to villagers with fevers. In her "doctor's bag" is an arsenal of medical small arms: oral rehy-dration salts, iron tablets, calcium pills, medication for various parasitic diseases, vitamin A capsules, cough medicine, lotion for scabies. She also carries her health register, educational posters, and a scale for weighing children.

From the other side of the hotel lobby, Lalita Edwards, the director of World Vision's Nawapur project, has been glancing over at Vasave and me. I motion to her, and she comes over to join us. When World Vision began its project in 1990 in the arid hills of Nawapur, only 31 percent of children had received their immunizations, says Edwards, a compact, confident woman who cuts to the heart of the matter when she speaks. Each month, more than 20 women in the region had miscarriages. Villagers drank a powerful locally brewed alcoholic beverage called "horo," and alcoholism was rampant. In one school, Edwards found that 16 out of 39 children between ages 7 and 9 regularly drank alcohol.

Since World Vision came on the scene, overall immunization coverage has climbed to at least 88 percent, says Edwards proudly. In all of 1993, only 38 women had miscarriages. World Vision also initiated health education programs for men's Farmer's Clubs and evening sports games, which have helped to cut down on alcohol abuse, says Edwards. Vasave joins in. "Previously there were umpteen diarrhea deaths," she says. "Now, community women can diagnose diarrhea before dehydration sets in. In 1990, there was not one diarrheal death. Last year, there was not one polio case."

How raising rabbits leads to better health

An hour's drive east of Bangalore, past rice paddies and corn fields, is a group of villages known as Mugalur. They are the site of a community health project directed by St. John's Medical College, a local Catholic organization that co-sponsored the Bangalore conference. One morning, a small group of us from the conference walk down the narrow dirt streets of one of the villages. As barefoot children peep out at us from behind the safe folds of their mothers' saris, some of us self-consciously snap photos. A young girl grinds seeds with a mortar and pestle into the gritty green paste that turns into red henna when smeared on foreheads and feet. A few horned water buffalo and cows loll in the street. After several blocks, we arrive at a small, airy health center run by St. John's.

Inside, professor of community health Dara Amar describes the college's involvement with the community. In addition to staffing two primary health centers and training local women to become health workers and midwives, St. John's has recently started providing poultry, sheep, and rabbits to rear: the seed capital for small-scale businesses.

The premise behind a medical college supporting rabbit rearing, explains Amar, "is that economic development is the entr‚e into health." By improving their economic standing, the thinking goes, women gain more purchasing power, which they can use to support the local health clinic or to buy medicines for their children. Otherwise, health services would get low priority behind immediate needs such as food.

We walk out back to a silo-shaped building to survey the "seed capital." Amar holds up a baby rabbit by the scruff of its neck, its multicolored fur lush like Irish moss. "The women saw people selling rabbit meat on the market and got the idea," he says. By breeding, raising, and selling rabbits for meat and pelts, a woman earns 30 to 40 rupees a day. The minimum wage is 20 rupees a day.

Do the village women understand the connection between the income-generating projects and health? Outside a house bordered by beautiful pink flowers, Jayamma Lakshmia, an older woman with gold nose rings and teeth turned red from betel-nut, is puzzled at first by this question. Then she energetically replies. "We just started the animal-rearing six months ago," she says as someone translates. "It's too early to talk about incoming capital and outgoing benefits. But we have used some money we earned to transport a person for emergency care to a local hospital." Rabbit farming has its other advantages. "Also," Lakshmia says, "when an important person came to the village, we cooked him a rabbit."

On the ride back, Dave Newberry, senior public health advisor for CARE, reflects, "I was struck by the fact that economic development appears to be going on first. My question is when will it all be tied back into health?"

There is evidence that the approach can work. In Nawapur, World Vision provided water buffalo to poor mothers, and trained them in how to rear the animals. Men also began tending the buffalo. As a result, alcoholism decreased, as did the incidence of spousal abuse, and women increased their savings, says Edwards. In Bangladesh, Save the Children has helped start women's savings and credit groups. So far, results suggest that children of credit union members are less likely to be malnourished and more likely to survive infancy than are children of women from an equivalent social class and geographic region who don't hold memberships.

Getting to the bottom of "soul loss"

Even though we're in India, conference participants get to travel around the world by watching slides of the project sites, such as those Dave Shanklin shows during his presentation. In one, a windowless concrete building sits alone on a hilltop. For as far as the eye can see, a succession of treeless hills roll out from the building, a health outpost run by Andean Rural Health Care (ARHC). The scene has a stark beauty, but it is also desolate and cold-- the very conditions that contribute to upper respiratory infections, a prime killer of infants in these high regions. Breathing in woodsmoke in closed homes, children are prone to respiratory infections. They are also far from medical treatment.

Dressed in jeans and a sport coat, his hair pulled back in a ponytail, Shanklin speaks passionately about his work as ARHC's program director in Bolivia, his voice thick with a Kentucky accent. Like other PVOs, ARHC provides a variety of healthcare services, mainly during home visits, he explains. For more sophisticated care, residents are referred to health outposts such as the one on the hilltop, or to urban hospitals.

ARHC also needs to determine whether its efforts are successful, says Shanklin. For example, does teaching women about the early warning signs of respiratory infection result in fewer children dying? So ARHC has developed strategies to measure the number of children who die over a certain time period and how they die, and to see whether those statistics change during the course of the interventions. That task has been extremely challenging.

Many residents are Aymara or Quechua Native Americans, who speak only their indigenous language, explains Shanklin. Many do not take kindly to strangers poking around with questions about children who died. As in most developing countries, most deaths in Bolivia occur at home, with no healthcare worker there to record the cause of death.

"People often don't know, don't want to know, or won't tell you the cause of death," says Shanklin. "Oftentimes when we ask the mother, she says susto." While the literal translation is "scare," parents use it to mean "soul loss," says Shanklin. "The child's soul chose to go away. It's hard to get past that to know what happened." The child could have been born prematurely at very low birthweight, and died from any number of confounding illnesses. "Mothers must face rage, depression, suicide--who knows," he says. "Susto is a way of coping. It wasn't meant to be." He adds quietly, "I think some of these infants are simply unde- sired."

In the past, obstacles such as these deterred PVO managers from attempting to measure mortality rates, or document the impact of their programs. "A lot of PVOs figured, if they serve, they're doing good," says Stan Foster, a visiting professor of international health at Emory University who's run health programs throughout the developing world. "How could they justify allocating scarce resources to monitoring impact?"

"But just because you think you're doing it right, you may not be," continues Foster. He cites a program in Bangladesh whose leaders claimed to have boosted tetanus immunization rates from 10 to 60 percent. Unfortunately, the vaccine turned out to be ineffective due to faulty manufacturing.

One of Hopkins's tasks is bringing its PVOs up to speed on statistical methods for assessing health needs, monitoring a project's effectiveness, and measuring its impact. In workshops given around the world, Hopkins Support Program staff teach PVO leaders lessons ranging from how to select a random sample of a population, to how to tabulate and analyze a huge stack of epidemiological data.

In Bolivia, one task of health workers trained by ARHC is to walk from home to home, collecting information about vital events--births, deaths, migrations. They visit every home in a community at least once a year, and homes with children more often. Because many of the health workers speak the local language and are known by the communities, says Shanklin, they already have a foot in the door, so to speak.

One technique that health workers learn is verbal autopsy, a method of establishing the cause of death months or years after it occurs. Health workers ask a specific series of questions--such as, "What happened in the hours before death?"--to come up with a medically based estimate. A parent might at first attribute a child's death to convulsions, for example. But through the paces of a verbal autopsy, the health worker may learn that the child had diarrhea for a week before dying, and can thus deduce that the cause of death was dehydration.

Despite all their limitations in gathering information, says Shanklin, ARHC managed to collect a statistically significant set of mortality data. The results, he says proudly, indicate that the mortality rate for children under 5 years has been cut in half since ARHC began work. "It's stunning. To save every other child that otherwise would have died. I'm in awe of it."

Knowledge is power

In a hotel room at the conference center, Ken Herman entertains a steady stream of PVO representatives, who flow through to try out a computerized tool known as ProMIS. At one point, the room looks like a software tutorial for a mini-United Nations, as a woman in a sari taps away at the keys of one terminal, a man in an African hat tries out another, and a woman in a woven Guatemalan jacket sits stumped at a third. Herman, personal computer manager for Save the Children, who also programmed ProMIS, is their coach.

The computer program, he explains, "is a tool for managing the large amount of data collected in community- based health information systems." Data on births, deaths, and migrations, for instance, or the date and severity of a case of malnutrition or diarrhea. Using ProMIS, this jumble of information can be analyzed in a matter of minutes, Herman says.

Health information systems like ProMIS have proven to be very powerful, says Jim Sarns, director of health, population, and nutrition for Save the Children. During the drought and famine in southern Sudan during the late 1980s, Save the Children used a system like ProMIS to identify two ethnic groups with high rates of malnutrition, who it turns out were not receiving their allotted government food rations. At the same time, they found, certain groups were getting 120 percent of the standard ration. Local community outreach workers trained by Save the Children then presented the data to government officials responsible for distributing the food rations, and convinced them to remedy the situation. Without the health information system, says Sarns, the discrepancy in food rationing might have remained hidden because in some regions, almost all Sudanese children were suffering from some degree of malnutrition.

As rations were distributed, Sarns reported, second- and third-degree malnutrition for children under five fell from 40 percent to less than 10 percent. "A health information system empowers people, even uneducated people," says Sarns. "You're arming people with data who now can go in and argue their point."

Include local organizations and governments

"Jesus is coming! Jesus is coming!"

When Stephen Robinson finally set foot in Rambuta village after a five-hour trek deep into the mountains of Indonesia's Molucca Islands, a boisterous group of children raced up to the thin, bearded man with these cries. The youngsters may have been teasing, says Robinson, but maybe they weren't. "It was something like 30 years since a Westerner had been to their village."

Sixty-five percent of the villages in the Moluccas--the "Spice Islands" Columbus sought--can only be reached by boat or on foot. "So if you get sick or need preventive healthcare like immunizations, you can't just hop in a taxi," says Robinson, who is the Asia regional technical advisor for Project Concern International.

Partly as a consequence of their remoteness, the Moluccas had the lowest immunization coverage in Indonesia as of 1990. Only 57 percent of children under age two had received measles and polio vaccines as compared to nationwide averages of 85 percent and 89 percent, respectively.

When Project Concern arrived in 1990, the Moluccas had a rural healthcare system. Each village or group of villages supported a volunteer-run health post, or Posyandu. Held monthly at the village chief's house, under a tree, or at the market, the Posyandu was intended to provide health services for children under five and pregnant women. In addition, a midwife, nurse, or other health professional from a regional health center was available to provide technical assistance and immunizations. Or so the theory went.

The reality was that in many villages, health professionals never visited, Posyandu weren't held, or few children were brought in. So Project Concern helped villages set up management teams, consisting of village chiefs and other leaders, to oversee the Posyandu. Each month, the teams collect information on the number of children who attended the Posyandu that month and the number of vaccinations administered. Within a district, the information is used to rank villages. The four lowest-ranked villages are reported to the district governor. Keeping score shows district health officials which Posyandu need the most attention, and also motivates management teams to improve their performance, says Robinson.

To increase Posyandu attendance, Project Concern and the Ministry of Education developed school workbooks with lessons on immunization, family planning, and vitamin A. Children complete the assignments with their mothers. "We figured, if we could teach students, they'd go home and teach their mothers," says Robinson. In some villages, children also take responsibility for making sure two of their neighbors go to the Posyandu.

In the two years since Project Concern began its innovations, the number of children receiving all of their immunizations by their first birthday climbed from 45 to 60 percent, and the number of children attending Posyandu each month increased from 30 percent to 48 percent. The Ministry of Education now has made the school education program part of its national fourth grade curriculum.

Like a network of tributaries, PVOs need to link up with many different organizations--schools, churches, and particularly local and national government, says Robinson. "Without working together with the government, non- governmental organizations like Project Concern cannot influence policy. So there can be no replication of their innovations. Also, turning it over to the government is one way of improving sustainability, because the government usually can set aside funding each year."

Think about the end at the beginning

The final test of a program's success, of course, is what happens in the months and years after the organization leaves. Will its projects crumble, or will communities continue to carry them out? This is the type of question we'll undoubtedly hear repeated as Congress reinspects our nation's foreign aid policy.

Cheryl Robertson is as qualified as anyone to answer the question. Vice president and volunteer for Minnesota International Health Volunteers, a tiny PVO, Robertson coordinated a community healthcare program funded during the mid 1980s in Kasangati, Uganda. In 1992, she returned to the region of lush rolling hills to conduct a follow-up evaluation four years later.

MIHV's program involved reviving services at a health center and training community health workers to serve the 35,000 residents of greater Kasangati. Community health workers were to focus on preventive health activities while referring the more demanding cases to government-sponsored public health nurses. Patients were to pay for drugs and curative care, while other costs were shared by the Ministry of Health, a neighboring university, and other organizations.

When Robertson returned to Kasangati, she found that the health center was thriving. Immunization rates and other health indicators had soared. Through interviews with staff and health workers, Robertson learned that the number of community health workers had increased by half. Health workers were highly regarded by the community, she says, and "they genuinely thought they were making a difference. They really thought they had a mission."

Unfortunately, there was a down side. While cost sharing was covering the health center's expenses, there just wasn't enough money to train health workers. An Oxfam grant had probably allowed the community to continue training workers for a while, says Robertson. But even that funding was dried up. "One thing after another would crop up," says Robertson. Last time she visited, the health center's roof had collapsed. "So do you use money for training or to repair the roof? The needs are inexhaustible."

Furthermore, due to lack of funding on its part, the government had stopped sending public health nurses into the region, so the community health workers were being asked to take on responsibilities beyond the scope of their limited training.

"I thought cost-sharing would be more of a panacea than it was," remarks Robertson. "Perhaps you also need to leave behind some beneficial funding, or have another agency continue to cover training expenses." Income-generating projects can help, but they cannot cover all costs of a community health project. "So it's important to have a realistic picture of what a community can support, and to recognize what isn't gonna fly."

I think about Robertson's experiences again the morning after the conference, while trying to take a taxi into Bangalore on my way to the airport. There is very little time, but the road is blocked. The day before, Hindu and Muslim students rioted in Bangalore, and Indian newspapers report seven people were killed. Businesses are closed. The government imposed a nighttime curfew, and ordered police to shoot violators. The police also blocked the road into the city from the hotel, on Bangalore's outskirts. My taxi driver starts to drive an alternate route, but turns around. He's a Tamil, he explains. He fears that the students, who have a history of clashing with Tamils, will "break my arms and legs."

The incident served as an apt backdrop to the entire conference. For in addition to drawing up plans to combat childhood diseases, linking up with governments and agencies, and promoting economic development, PVOs must function amidst a volatile climate of ethnic strife. Simply driving down a road can be a challenge. The real roadblocks to success--violence, poverty, plague, environmental degradation, floods--threaten and sometimes overwhelm the effectiveness of health programs.

The final measure of success is whether, despite such obstacles, communities can continue to help more of their children reach adulthood.

Senior science writer Melissa Hendricks wishes to thank Karunesh Tuli and Bart Burkhalter for providing background information for this article.

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