Articles by Caitlin McQuilling

Caitlin is heading up RMF’s program to eradicate childhood malnutrition in Madhya Pradesh , India. A native of New York, Caitlin has been living in New Delhi since August 2007 working on HIV/AIDS diagnostics and treatment. She has worked with the national government on supply chain, forecasting, quality assurance testing, trainings, and advocacy for new technologies and best practices. She was instrumental in introducing early infant diagnosis of HIV into the country. Caitlin has also spent time living, studying and working as a researcher and translator for an economic think tank in Sao Paulo, Brazil. Caitlin graduated from Georgetown University’s School of Foreign Service with a BS in International Politics, focusing on international law institutions, and ethics. She speaks Spanish and Portuguese and is determined to master Hindi. Caitlin enjoys cruising the streets of New Delhi on her scooter, experimenting with Indian cooking, and snowboarding in Kashmir.

Pakistan’s hospitality

July 12, 2010 in Caitlin McQuilling, General, Voices from the Field by Caitlin McQuilling | Comments closed

This is a post for my mother. Everyone who hears that Real Medicine Foundation is working in Pakistan wonders about the security. All we hear about Pakistan in the media is about the violence and War on Terror. I have to admit, despite being a seasoned traveler, as a blonde American I was a little worried about my trip to Pakistan to visit RMF’s clinic in Balakot, KPK (formerly NWFP), especially when blast went off at a famous Sufi shrine in Lahore a day before my arrival. After two weeks in Pakistan however, I have to say that I’ve been completely safe and have enjoyed a warm reception everywhere I’ve gone.

In Balakot, I was greeted with nothing but hospitality and gratitude. While the kids stared and giggled, the mothers eagerly spoke to me about their problems and thanked me for RMF’s help. No one asked about my nationality or politics – they only cared that I was there to help. Dr. Martina Fuchs also had a similar experience visiting the Balakot clinic last year. On her visit the local leaders organized an unprecedented community meeting, bringing together a variety of stakeholders (who often can’t be in the same room together) from the community to talk about the health care needs of Balakot and the roll of our clinic. A few of the patients I met on my visit to Balakot remembered Martina and enthusiastically asked about her, her family, and sent their best wishes.

This kind of hospitality is not unique. The people of Mansehra and Pakistan as a whole are known for their warmth and care for visitors. It’s only in the past few years, with the encroachment of the Taliban into KPK that this area has gotten a dangerous reputation.

The limits of Tailban influence - not yet in Mansehra

Mansehra district where we’re working is not Taliban infiltrated according to local accounts. Located a few hours away from the dangerous Swat valley, Mansehra is a pretty stable and peaceful area. While some NGOs have moved their staff out of KPK for safety reasons, our staff is completely secure – the local community protects them. Our doctor told me a touching story: Last year in the chaos that followed Benazir Bhutto’s assassination there was widespread rioting in the valley. Buildings were being torched and raided and cars overturned. At onset of violence, a group of men from the village nearby rushed over to the clinic to protect it from possible attack or looting. These men took turns guarding their clinic for a week until the violence subsided.

It also helps that most of our staff is from Balakot. The medical technician, pharmacist and maintenance staff are all locals and the doctor and Ladies Health Workers are practically locals since they’ve lived on-site in Balakot since 2005.

Pakistan may be a dangerous place caught in the war on terror, but as in any conflict around the world, while leaders gesture and bombs go off, it’s the local populations who suffer the most. The people in Pakistan want the same thing that people all over the world want: to be able to raise a healthy, happy family. They want education, healthcare, and livelihood, not all of this drama that has been thrust upon them. I have never once felt threatened while here, thanks to the hospitality of our local staff and friends.

Real Medicine Foundation is dedicated to Pakistan and we see the overwhelming need for our work here. As an organization, security for our staff is of course our number one priority, but we will continue to provide assistance to the people here as long as we can.

So don’t worry mom, I’m in good hands.

Still Providing Real Medicine in Pakistan

July 11, 2010 in Caitlin McQuilling, General, Pakistan, Voices from the Field by Caitlin McQuilling | 1 comment

Today I had the privilege of visiting RMF’s Clinic in Talhatta, Balakot, KPK (formerly NWFP). I have to admit I didn’t quite believe the RMF team when they said that we’re the only health care provider in Balakot, the valley worst hit by the 2005 earthquake and with a population of over 120,000 people. While I had no doubt that RMF must be doing amazing work in Balakot, I assumed there had to be other NGOs providing health care. Hadn’t the whole world run up to the mountains of NWFP after the earthquake? Doesn’t USAID give billions to Pakistan? I was incredulous.

Today I got the chance to not only see for myself the amazing work we’re doing, but also see for myself that we are the only ones providing health care. Driving through the valley, the roadside is littered with placards announcing the donation of every NGO and government under the sun but five years later everyone has pulled out. There is one small government hospital, a beautiful brand new facility which is tragically underutilized: the x-ray room and laboratory remained locked, the doctors too busy in their private practices, and OPD hours shortened.

In the 5 years since the earthquake, the valley of Balakot is swarming with life again as families have worked to gain back their livelihoods. But they haven’t built back. Since this area is still a disaster prone area, the government has not allowed the residents to build their homes again. The residents have been promised relocations, but 5 years after the earthquake they’re still living in temporary shelters and tents with no prospect of moving since the new “earthquake victims colony” being built in the next valley over is quickly being filled by wealthy residents from other areas.

In limbo, the residents of Balakot live in a semi-refugee status, with nowhere to go and none of the resources that the Internally Displaced People (IDPs) in other areas of the country are getting. Where everyday life such a struggle, at least the residents of Balakot have one silver lining: RMF’s clinic.

Located in a central point in the valley, our clinic provides high quality basic health care free of cost and provides patients transportation to the nearest district hospital (3 hours away) in our jeep/ambulance for serious cases. With the mountains in the background and wild flowers growing in front of the facility, the clinic looks as if it should be the location of a mountain resort. Instead, RMF has 4 functional buildings – made out of concrete and sheet metal – which serve as the doctors exam room, the women’s exam room, the pharmacy, and a small in-patient unit. We also have a temporary premade building which houses the doctor and medical technician who live on-site.

In the women’s unit, our incredible Ladies Health Workers give ante-natal check-ups, exams, and family planning services (counseling, IUDs, injections, etc). Our doctor and medical technician provide expert medical care, treating everything from wounds to respiratory infections and malaria. Our pharmacy is fully stocked and free of cost to the patients.

I spoke to some of the patient outside the clinic. One woman coming for her ante-natal check-up said that she had walked for 3 hours down from her village in the mountains to get to our clinic. When I asked her why she came all this way, she told me how the Lady Health Workers had counseled her on how important regular ante-natal check-ups are for her and for her baby. She plans on having the baby at our facility.

I asked another patient how she heard about this facility, a question which confused this woman. “How did I hear about it? Everyone knows about this clinic. It’s the only place to go.”

One of the best parts about observing the buzzing clinic and watching all these women and children get treatment from our compassionate staff was the fact that my visit was unannounced. For security reasons I did not tell anyone I was coming up to the clinic, so when I arrived to see everything fully functioning and moving, I knew that all of our reports from the clinic were true.

While Balakot is no longer in the international limelight, RMF has committed to helping the community. This is no longer a post-earthquake emergency intervention, but a program which provides essential services to a community who is in deparate need of them.

Help us help Balakot. Donate at www.realmedicinefoundation.org

Tags: balakot, clinic, field report, hashoo foundation, Pakistan

Jyoti: A New Light

June 27, 2010 in General by Caitlin McQuilling | Comments closed

One of the most touching events of my life happened today at the RMF Nutrition Rehabilitation Center at Jeevan Jyoti Hospital. The mother of one of our patients decided to name her new baby, Jyoti, after our NRC.

Neha came in 18 days ago as one of the most serious cases we had seen yet at the NRC. Neha, two years old, weighed just 4 kgs, had a blistering fungal infection, a fever, and lymph nodes which suggested TB. She was immediately admitted to a private room to avoid possibly spreading her infection to other patients and was started right away on therapeutic milk, an antibiotic, and anti-fungal medication.

At admission, Neha’s mother, Hakari, told us that she was about 7 months pregnant, but wasn’t exactly sure because she never had a pre-natal exam. We scheduled one for her the next day and then settled the patients and their families down for the night. We were in for quite the surprise! That first night Hakari started having contractions while Premlata, our staff nurse, was giving the children one of their 2 hourly nightly feeds. At 5am, our first NRC baby was born (upstairs in the delivery room)! A healthy baby girl weighing 2.9 kg!

As per custom, the baby does not receive a name until an auspicious day and time. While it is also customary for most women go to their mother’s home for the first few weeks after delivery, we convinced Hakari that it was essential for Neha to stay at the hospital so that she could receive her full course of treatment and start her tuberculosis medications (she was diagnosed as positive the next day). Hakari realized the importance of the NRC not just for Neha, but for the new baby, so sent for her mother to come stay at the NRC as well.

For the past 2 weeks, Hakari, Neha, grandma and the baby have stayed with us at the NRC. While the baby has mostly slept all day, mom and Neha got to bond and play as Neha gained more and more energy and weight. She’s already gained over a kilo! Hakari is receiving hearty, healthy food and is counseled daily by our staff on breastfeeding, infant and young child care practices, and family planning. Our NRC baby has received all her immunizations and is cute cute cute!

Today, Hakari made a touching announcement to our staff. The family has decided to name the baby Jyoti, light in Hindi, after our NRC at Jeevan Jyoti hospital (I guess Real Medicine didn’t have the same ring). Hakari says that her stay at the NRC has changed her life and will forever impact the lives of her children. She wants to honor us and honor her child by naming the child, Jyoti, after our NRC. Jyoti, she said, will be a constant reminder of what she’s learned at the NRC and how to keep her child healthy.

It really doesn’t get better than this.

Neha and her new sister Jyoti

Linkages, Linkages Everywhere

June 26, 2010 in General by Caitlin McQuilling | Comments closed

“Creating linkages” is ones of the favorite buzzwords amongst NGOs. Linkages are referred to at big conferences and in widely distributed concept papers. A concept that seems quite simple – connecting people to the resources they need from across programs and sectors – has become a development field in itself with its own set of experts, grants, and conferences.

At RMF we don’t write proposals about linkages, start separate programs to promote them, or hire new staff specializing in linkages – they just happen in RMF’s programs because of our incredibly resourceful staff who focus on the person as a whole. While our HIV/AIDS and malnutrition programs are primarily health focused, we do everything we can to link our patients and the families we meet to other resources available to help them where we can’t. Part of the definition of RMF is that our programs do not exist in silos.

Two weeks into our NRC and our programs are already complimenting each other. Our CNEs, the field staff of our malnutrition program, are bringing in children from their villages to the NRC and spending all their non-field time in the NRC, hanging out with the mothers and giving one on one counseling. One of the children we admitted in the NRC was brought in by one of our HIV counselors, an HIV+ malnourished child. This child is doing well with the therapeutic nutrition we’re offering but will require much more extensive follow-up than the non HIV positive children. Our nutrition staff will train our HIV counselor on how to work with the family to ensure that this child gets proper nutrition and will also make home visits to follow-up.

Another one of our HIV/AIDS program volunteers, an HIV+ individual who regularly volunteers with our program and is also an anganwadi (village health worker), has already referred 3 children to our center, giving them counseling about the quality of care available with us that she has firsthand knowledge about. This woman stops by to visit the families she has referred whenever she comes in for her anti-retroviral therapy or attends counseling sessions at our office.

And the linkages don’t stop between one RMF program to another RMF program Our staff make every effort to link the families we interact with to all services available to them. The central mantra of our childhood malnutrition program is to “connect families to the resources available to identify, treat, and prevent malnutrition.” We connect families to government services such as discounted grains through PDS, health services at anganwadi centers, schools, work through NREGA, and more. In our HIV/AIDS program, we connect HIV positive individuals to livelihood programs supported by another local NGO, Pragati, and have also arranged for 6 HIV positive children to attend a boarding school in Ujjain, run by another NGO, free of cost.

These linkages are always mutually beneficial. Later this month, our nutrition field staff in Jhabua will train staff members of MPRLP on how to identify malnutrition in the field. MPRLP (http://www.mprlp.in/) supports livelihood projects in rural areas throughout Jhabua, providing guidance to the National Rural Employment Guarantee Act schemes. We’re simply giving their staff information about malnutrition since they’re often in villages where malnutrition is extremely high and want to know how to refer serious cases they may find for further help. However, beyond this simple training, we’re also building a relationship with an organization who can help our communities where we leave off. In the long-term our families will need access to sustainably livelihoods in their communities without having to migrate for work. We can help link these families to MPRLP, improving their living conditions and child’s health. Based on the community needs assessments we conducted in our villages during our baseline surveys, we will also be providing MPRLP with a list of priority villages for their livelihood programs and some ideas of projects they could take on which would benefit the community.

The linkages go on and on – from connecting female sex workers to literacy classes to introducing an NGO who works on clean water to all our contacts in MP, we’re using our networks and staff’s resourcefulness to make an impact far larger than what we could do alone.

The Neighborhood Endowment Fund Program in Central Java – a Reflection

June 23, 2010 in Indonesia by Caitlin McQuilling | Comments closed

June 17, 2010 by Caitlin McQuilling and Sahil Sondhi

Now four years into RMF’s partnership with KOMPIP, RMF is taking a step back to reflect on the successes of our joint Neighborhood Endowment Fund Program thus far.

This community-owned revolving fund initiative provides its members with access to small loans for micro-enterprise purposes. Each neighborhood has its own fund and democratically elects three to four people to administer the fund voluntarily, acting in the capacities of leader, treasurer and secretary. The neighborhood structure that is already in existence is the pillar of the program. In Indonesia this structure is known as the “RT-RW” system of socio-geographic organization.

Each defined geographic area is divided up into neighborhoods that are identifiable by this RT-RW marker and these cohesive neighborhood groups are instilled with a communal sense of ownership and responsibility of their NEF. The amount received by each neighborhood is generally sufficient for two simultaneous borrowers of up to US$100 each and at a monthly interest rate of 1% to 1.5%. In addition to designing and field testing this system, KOMPIP and RMF have provided basic microcredit bookkeeping training, micro business management training, micro business marketing training and solidarity building to the neighborhoods receiving these funds so that communities can maximize their own results.

Out of 198 original neighborhoods in Yogyajakarta and Klaten, Central Java, 193 neighborhoods (with a membership of 7,000 people) successfully became self-sustainable. Loan repayment rates have been close to 100% and NEF communities have responded well to KOMPIP and RMF’s hands-on approach at facilitating these loans. Additionally, in all 193 neighborhoods the revolving funds have grown substantially larger, allowing for increased access and larger loans.

Through field visits to a selection of these neighborhood communities, KOMPIP has documented substantial changes in the standards of living of NEF communities. Borrowers have improved their neighborhood communities’ access to healthcare and education and have increased their incomes, quality of housing, and levels of empowerment. RMF and KOMPIP have successfully created livelihoods for thousands of people and have initiated a “multiplier” effect in that the revolving funds in at least 193 neighborhood communities continue to rotate from borrower to borrower, creating microenterprises and employment

One significant advantage of community-owned microfinance units such as KOMPIP-RMF’s NEF is the solid financial performance that is observed. This is attributable to the communal sense of ownership of respective neighborhood-level funds as well as the peer pressure that results from such a collectivist system in which neighborhood members are mutually dependent upon each other. Additionally, overhead costs continue to be low and the cohesive and communal nature of the neighborhood groups greatly reduces risk since prospective borrowers are screened by those that know their strengths and weaknesses best.

Expansion

Due to the extraordinary success achieved, measured by increasing incomes and standards of living, KOMPIP, RMF and the local government of Solo entered into a partnership to replicate the NEF model to the entire Surakarta area, encompassing 2668 neighborhoods and 100,000 people. RMF and KOMPIP were able to put in modest organizational funds in order to leverage a $250,000 pledge by the local government of Surakarta.

RMF and KOMPIP used their resources to monitor the distribution of this government grant and to introduce the NEF concept to the larger Surakarta area. RMF and KOMPIP held socialization events and workshops at the city level and at the district level and aided with the distribution of seed grants to neighborhood communities. These activities were extremely well received by the community, with approximately 3000 people attending the first NEF socialization

RMF’s impact is best said by KOMPIP’s Director, Pak Akbar below:

“I think that the impact that can already been seen from the US$10,000 provided by RMF is that it stimulated the local government of Solo to allocate the seed grant of Rp. 2.3 billion (US$250,000). In other words, the funds of US$10,000 created the allocation of 2500% additional funds from the local government relative to the amount paid by RMF. From this figure, we can see how big the influence of RMF-KOMPIP to the local government of Surakarta has been.”

Since the increased NEF funds were only released months ago, it is difficult to measure the qualitative impact of this seed money on local communities. RMF and KOMPIP will offer the Mayor’s Office any help we can to assess the impact of this grant and to move the program forwards. The local government of Surakarta continues to offer support for the NEF initiative and may be able to help revive these newest NEF members in the next fiscal year.

The relationship and trust built with the government of Surakarta will be invaluable – RMF and/or KOMPIP will be able to make use of this relationship in future endeavors. Moving forwards RMF will continue with these relationships and will build upon the successes of the NEF’s with a focus on livelihood support and innovation for those taking NEF loans and also on quality of NEF services.

Learn more about RMF Indonesia

A Letter from the Mayor of Surakarta

The Energy of the NRC

June 21, 2010 in India by Caitlin McQuilling | Comments closed

Two weeks ago the children we admitted we listless and dull-eyed. Many were so dehydrated that when they cried there were no tears; the children were often too weak to make much noise at all. Now as I write this I’m sitting in the middle of recovery – and its very loud. After two weeks of therapeutic milk, micro-nutrients, and medicines, the children have gained weight and found new energy. Two year old’s who have never walked are teetering on the edge of chairs, about to take off. Toys no one touched are now being fought over. They have the energy to fight! And to cry! It’s absolutely magical to see how two weeks of good medicine and therapy can transform a child – it’s brought their spirit back. The energy of this chaotic room is tangible. So tangible that I have quite the headache.

The mothers too are now at ease and starting to enjoy this process. These women who have so much housework at home on their farms and with their multiple children now have the time to sit and bond and play with their children and get to know other mothers. They’re all hanging out in our breezy, cheerful recreation room, spending time together while the kids play, and taking turns learning how to cook nutritious meals for each other. They’re asking questions, getting more and more involved in group discussions and jumping in to counsel the parents of new patients about the importance of staying at the NRC for the full course of treatment.

Between the uphill battle of getting our NRC approved and operational and the stress of opening a center to cater to acutely ill patients, I haven’t been able to fully enjoy what an amazing place this is until right now as children run all around me and try to help with my typing. Shsdhfsoahsdfndsjcnosh.

I’m looking forward to watching this center evolve into a center of excellence and seeing this amazing cycle of recovery occur time and again with new children and new mothers.

New Initiative: Increasing Access to HIV/AIDS, STI, and Women’s Health Services for some of India’s Most Vulnerable Women

June 7, 2010 in India, Initiatives by Caitlin McQuilling | Comments closed

by Caitlin McQuilling, Director, South Asia

It has recently been estimated that there are approximately 2.8 million female sex workers in India, an estimated 36% of whom are under the age of 18. These women are some of the most vulnerable in India to HIV/AIDS and STIs and some of the most underserved, especially in rural areas where their networks are more difficult to target and their access to health services most limited.

Real Medicine Foundation is proud to announce that we’ve tied up with UNFPA and our local partner Jeevan Jyoti Health Service Society to provide access to HIV/AIDS, STI, and basic women’s health services for some of the most vulnerable female sex workers in the country. Our goal is to provide these women with the knowledge and tools to prevent HIV/AIDS and STIs and also to provide and facilitate access to counseling, testing and treatment when required.

We will be working in two districts, Jhabua and Nimach in Western Madhya Pradesh where we are targeting two very different communities, the Banchhara tribal community in Nimach where sex work has been an accepted community tradition for generations, and the tribal communities in Jhabua, where female sex workers have mobile networks of regular clients. While both communities are located in “low prevalence” areas, they are extremely vulnerable to HIV, the Banchhara because of their location on one of the most congested trucking routes in the country, the Bhils because of high levels of migration in their area, and both because of their low literacy rates and scarcity of health services.

In addition to counseling and directing services towards the female sex workers themselves, we will also engage with the communities where these women work to make sure there is an enabling environment for them to seek services and that key community members such as pimps, clients, and owners of establishments that these women frequent are informed about HIV/AIDS and STIs and that they also have access to free counseling, testing, and treatment. We will provide training on HIV/AIDS and STIs to doctors who are the preferred care providers for female sex workers and will be offering them incentives to hold weekly health camps and screenings to benefit all women in areas where female sex workers live and work.

The RMF Team is humbled but enthusiastic to be taking on this difficult initiative. While there will be many challenges working in this sometimes controversial area with such sensitive populations, we also see the overwhelming need to serve these women who have suffered unimaginable burdens. During our staff interviews, project site locations, and focus group discussions over the past few months, we’ve met with many current and former female sex workers. As these women open up and begin to trust you, their amazing spirits come out while telling of their hardships and experiences. What is even more heartbreaking than seeing these beautiful young girls involved in this business, is to see these beautiful young girls exposed to such risks. Most of the women we met had some idea about the danger of HIV and STIs, but there are still many misconceptions and gaps in knowledge. They have almost zero access to health services in their areas and often face discrimination from government hospitals.

With the help of the local community, including current and former female sex workers, we hope to close this gap and to empower these women with the knowledge, tools, and facilities they need to prevent the spread of HIV/AIDS and STIs and to focus on long-term women’s health for the whole community. We begin this program knowing that we will have to rely on local communities to help us understand the nuances and complexities of healthcare provision in these areas and will tailor all of our efforts as best as we can to the needs of Jhabua’s and Nimach’s vulnerable populations.

For those of you who want to read more about the risk of HIV/AIDS for Female Sex Workers in rural India, I’ve included a background below.

HIV/AIDS and Female Sex Workers (FSWs) in Madhya Pradesh

In 2006, it was estimated that between 2 million and 3.1 million people were living with HIV in India. Once localized predominantly to the cities, evidence suggests that HIV/AIDS is now spreading to rural communities. Madhya Pradesh, traditionally considered a low prevalent state, has seen HIV spreading at alarming rates throughout rural areas that are rife with risk factors – low literacy, lack of knowledge about general health issues, especially HIV, high migration rates to nearby high prevalence areas, frequent interaction with female sex-workers, a high number of adolescents, and proximity of major trucking routes. HIV/AIDS in Madhya Pradesh is spread to rural communities through bridge populations and groups partaking in high risk behavior. Especially in Western Madhya Pradesh, which sits upon a major trucking route and is close enough for regular migration to Ahmedabad and Indore, HIV is spread by bridge populations – migrants and truckers – visiting Female Sex Workers (FSWs) and bringing HIV back home to their families in rural areas.

FSWs in Western Madhya Pradesh are non-brothel based, often working in small shacks close to trucking routes and in locations known to the general communities. A factor of great concern is that HIV is being spread amongst communities virtually unaware of HIV by bridge populations and high risk groups with a similar lack of knowledge about HIV and STIs.

HIV-related knowledge is a critical component of prevention, but statistics from the 2005-2006 National Family Health Survey-3 (NFHS-3) show that while about 74 percent of women and 95 percent of men in urban areas have heard of AIDS, those living in rural communities are far less educated about the disease. Only 35 percent of women and 59 percent of men in rural Madhya Pradesh have ever heard of AIDS. Furthermore, in rural areas, far less is known about the protective benefits of condom use. Fewer than half as many women in rural areas versus urban areas (26 percent versus 63 percent) understand that consistent condom use can reduce HIV transmission. The statistics for men show slightly better, though still inadequate, rates of understanding regarding HIV transmission, thus emphasizing the vulnerability of this population to HIV (Figure 1).² The Behavioural Surveillance 2006 reports that only 50% of the sex workers are aware of STIs and fewer get treated for STIs (31%) in the government hospitals or clinics.

Figure 1. The percentage of married adults aged 14 to 49 who have heard of AIDS in 1998-1999 compared to 2005-2006 (NFHS-3). National Family Health Survey-3 (NFHS-3). Deonar, Mumbai, International Institute for Population Sciences, 2005-2006.

Given the spread of HIV from urban to rural areas combined with the lack of knowledge about HIV, STIs, and condom usage, there is urgent need to focus a targeted intervention on at-risk groups in Western Madhya Pradesh. Focusing on FSWs and their communities can help halt the spread of HIV amongst bridge populations.

Background on RMF districts: Jhabua and Nimach

JJHSS proposes targeted interventions in two districts of Madhya Pradesh, Jhabua because of its alarming rate of HIV growth combined with FSW spread throughout the district and Nimach because of the large FSW population concentrated along Nimach’s trucking route. Both communities have large FSW populations that are highly integrated into parts of the community – whether in terms of their client network in Jhabua or their community of FSW such as in Nimach.

HIV/AIDS in Jhabua

Jhabua district in the Western-most part of Madhya Pradesh is 91 percent rural, 85 percent tribal, and has among the lowest literacy rates of the country.^3,4 More than half of its 1.2 million tribal inhabitants live as marginal farmers below the poverty line and periodically migrate to the adjacent states of Gujarat and Maharashtra.⁵ In 2002, the HIV prevalence among high-risk groups in Gujarat was more than five percent. In the same year, Maharashtra was identified as a high-prevalence state, with more than one percent of pregnant women infected with HIV.⁶ Many tribal inhabitants from Jhabua work as migrant laborers in these urban areas where they are exposed to a number to risk-factors for HIV, including sexual exploitation and contact with commercial sex workers.

Due in large part to the HIV prevention efforts of organizations throughout the state, the 2006 HIV Sentinel Surveillance data shows that the prevalence of HIV in Madhya Pradesh has remained relatively stable (0.17 in 2002 to 0.11 in 2006).⁷ Though state-wide data suggest stability in HIV prevalence, cases of HIV in the Jhabua area seem to be on the rise. At the project’s inception approximately two years ago, Jeevan Jyoti Health Services Society was facilitating care for 54 patients infected with HIV. This number continues to rise, with an average of six to seven new cases being identified each month (Figure 2).

The alarming rate of new HIV case detection, combined with the presence of FSW in each village of the district, signals the necessity for a community based intervention to promote awareness on safe sex and to increase the coverage of HIV/STI testing and treatment, especially amongst FSW populations.

FSWs in Jhabua are non brothel based and are spread out throughout the district in almost every other village. They don’t advertise on the streets, but get their business through contacts and a network of clients. They typically have 15-20 clients at a time whom they call and arrange business with. These FSWs live at home with their families and often rent rooms to conduct business or work with local wine shops.

HIV in Nimach – a community

While in Jhabua sex workers operate through informal networks of clients, in Nimach, sex work is tied to a centuries old community practice and is deeply rooted in the tradition and economy of the Banchhara tribal community of the area. According to a report prepared by the Madhya Pradesh State Human Rights Commission, the Banchhara community which practices caste-based prostitution mainly exists in the Ratlam, Neemuch and Mandsaur districts of Madhya Pradesh, bordering Madhya Pradesh from where they are believed to have migrated some 500 years ago.

According to the report their total population is 5,775, including 3,113 females. There are 1,212 unmarried girls in the community of whom 45 percent are engaged in prostitution. The Banchhara females are divided into two groups. Those who marry are known as Bhattawadi and those reserved for prostitution are called Khelawadi. A Bhattawadi cannot engage in prostitution and a Khelawadi cannot marry. The mother has the right to decide which of her daughters will marry and which will become a sex worker. It is obligatory for the mother to dedicate at least one of her daughters to the flesh trade. She has to make the choice in the girl’s early childhood and declare it before the community’s deity, Nari Mata.

The Khelawadis conduct their business in small huts situated near highways as most of the customers are truckers. The fathers and brothers act as pimps. Banchhara women abandon prostitution after the age of 35, when they are considered old and do not get customers. By then many contract sexually transmitted diseases.

A recent health check conducted amongst Banchhara sex workers in Mandsaur and Nimach districts of the state showed that 50 percent of them were HIV positive. The report of the MPHRC on both the communities says that Banchharas could be considered affluent. “It is therefore possible to infer that prostitution amongst Banchharas is not an economic necessity. It is more a social custom or convention,” it says. Earlier all the girls were debarred from marriage and it was obligatory for them to support their families through prostitution. But that is not the case any longer.

In 2006 JJHHS in partnership with the District Collector of Ratlam assisted in an FSW survey along the 110 km that connect Ratlam and Nimach, passing through Mandsaur. This survey identified 1,434 FSW hailing from 768 Banchhara families. We estimate that there are between 600-700 FSW currently in Nimach, but would need to conduct another survey to confirm this.

While government schemes are in place to assist these FSW, there is still much to be done to address HIV in this vulnerable population. There are currently only 3 ICTC centers for counseling and testing available for these women (one each in Ratlam, Madsaur and Nimach) and only one ART center for treatment.

¹ HIV Sentinel Surveillance (HSS) Technical Report: India, HIV Estimates – 2006. National AIDS Control
Organisation (NACO), 2006.

² National Family Health Survey-3 (NFHS-3). Deonar, Mumbai, International Institute for Population Sciences,
2005- 2006.

³ Jhabua: Statistical Profile. National Informatics Centre, Madhya Pradesh, 2001 Census data.
http://jhabua.nic.in/factfile.htm

⁴ Annual Status of Education Report (ASER) 2007. Facilitated by Pratham, New Delhi, India, 2007.

⁵ Jhabua: Statistical Profile. National Informatics Centre, Madhya Pradesh, 2005. http://jhabua.nic.in/factfile.htm.

⁶ HIV Epidemic in India, Maps 2002. UNAIDS India, 2006. http://www.unaids.org.in/.

⁷ HIV Sentinel Surveillance (HSS) Technical Report: India, HIV Estimates – 2006. National AIDS Control
Organisation (NACO), 2006.

RMF India Thanks Our Incredible Medical Volunteers

May 22, 2010 in General by Caitlin McQuilling | Comments closed

Setu and Matt in Bhil Academy's Health Center

Matt Oerti and Tyler Cherin just graduated from Harvard Medical School and are bracing for their next big step, beginning their residencies, moving to new cities, and giving up sleep (which they already sorely miss). While many of their classmates decided to take this time between the pressures of med school and the hectic life of residency for well-deserved rest and relaxation, Tyler and Matt flew across the world to return to the sweltering heat of Jhabua, a rural town in Madhya Pradesh, India, to help RMF for a month.

At the same time, Setu Patel, an American Physicians Assistant, decided to also generously donate her vacation time while visiting family in India, to come to Jhabua and lend a much needed hand.

One day off the plane, Tyler and Matt battled jetlag to help hold the Bhil Academy’s annual health camp for perspective students and their families. With the help of Setu and our local medical team, they screened over 200 children and referred serious cases for follow-up at our partner hospital. The hectic schedule continued.

During their time here, Matt, Setu, and Tyler focused their time on both individual patients and addressing long-term systematic needs. They helped us create a training program for our new nutrition rehabilitation center staff, helped procure better medical equipment for our field health team, and focused on quality of care, especially emergency care at our partner hospital, Jeevan Jyoti Health Service Society. As with all our programs, things don’t always go as expected and Matt, Tyler, and Setu stepped up to the challenges and adapted to situations. When one of our health worker’s daughters fell seriously ill, they acted and immediately arranged to take the entire family to a specialty hospital in Ahmadabad, 10 hours away, without a second thought.

The students at the Bhil Academy loved having the group to hang out with everyday. Even though the group has only been gone for a few weeks now, many of the students have already written letters to them for us to send to the US.

Vinay, one of our brightest 9^th class students, was one of the most excited to see Tyler and Matt returning. Last year when Tyler and Matt volunteered with us in Jhabua they had helped with the medical care of Vinay’s father. Despite all our efforts, unfortunately Vinay’s father passed away and the family was stuck with crippling medical debts. Vinay’s family told us that they would need to pull him out of school so he could support the family in working to pay back the medical debts. When Tyler found out about this back in the US, he immediately initiated a campaign through his friends and family to raise money to pay Vinay’s family’s debts. Tyler was able to raise enough money in weeks to be able to repay the debts and keep Vinay in school. It was touching to see Vinay and Tyler’s first interaction since being back. Vinay was counting down the days until Tyler’s arrival, but once Tyler arrived he was nervous to see him: As a popular 14 year old he was embarrassed he might start crying in front of his classmates. Vinay is still one of the best performers in school, all thanks to Tyler’s efforts to keep him there.

Dr. Tyler - sorries ladies and gentleman, he's taken!

We thank Matt, Setu, and Tyler for giving up their vacations to work tirelessly for our friends in Jhabua. It was an incredible pick-me-up for the RMF staff to have such dedicated, positive, and interesting people here for the month. We learned a great deal from the crew – from Setu’s advanced clinical experience and cooking skills to Matt’s ability to connect with patients and grasp both medical and psychological needs to Tyler’s ability to translate difficult concepts into easy to follow guidelines. We were lucky to have volunteers who came and made a huge impact to our programs and who also made us laugh.

RMF’s doors are always open to bright, driven, passionate volunteers like Setu, Tyler, and Matt. Please contact us if you’re interested in finding out more about how to volunteer your time and skills both in the field and back home.

The Barwani Nutrition Team – Wearing Us Out

April 20, 2010 in General by Caitlin McQuilling | Comments closed

Today Michael and I joined our team of Community Nutrition Educators in Barwani district in the field to see how their work is going. We set out to Dekhaliya village in the Parti Block of Barwani district, considered one of the most remote blocks in all of India. After leaving the paved road behind and travelling across a pitted tractor path, our jeep could not continue any further, leaving us on the banks of a bridgeless, dry riverbed. With no other choice, the entire team took off on foot up craggy hills and across streams. We battled blinding sandstorms and 118 degree heat, without a complaint from our bubbly, enthusiastic staff. We spent the day watching how each worker approaches a household, measuring each child using a MUAC tape (measurement of mid-upper arm circumference), and counsels the family on good nutrition and overall child health. We continue to be immensely impressed by the staff, not only for their great communication skills and ability to connect with the families of malnourished children, but also for their willingness to endure these extreme conditions and terrain.

A few pictures from our day:

Its as hot as it looks

Barwani staff

Mid-stream MUAC

Fishing - good protein!

House calls

on the road

Barwani staff debriefing

Early Success: One Child at a Time

April 19, 2010 in India by Caitlin McQuilling | Comments closed

As our teams have finished their baseline surveys and are now moving on to the intervention stage of our childhood malnutrition program, we’re excited to already be seeing successes. A few days ago I went out with one of our community nutrition educators, Priyanka, from Alirajpur, to see how the team is doing with their trainings and individual household counseling sessions.

Priyanka, one of RMF's Community Nutrition Educators, Kashish, and Ranu

Priyanka and I visited Chota Undava village which Priyanka had already visited twice, once during the baseline and once to follow-up with malnourished patients she identified. We entered the village and Priyanka knew exactly which households to go to where children with moderate or severe acute malnutrition lived. The first house we stopped at was the home of Kasish and Kishore, who’s youngest child Ranu, 1 ½, Priyanka had identified as severely malnourished one month ago. Ranu measured a 110mm around her mid-upper arm (MUAC), and while Priyanka spent hours trying to convince the family to go to the Nutrition Rehabilitation Center, the family refused to go because of their 4 other children at home and work commitments. Priyanka counseled this family extensively on the effects of malnutrition and ways in which they could improve their child’s health at home, including improved breastfeeding, regular supplemental feeding using locally available nutritious foods, and improved sanitation and hygiene. She coordinated with the local anganwadi worker (village health worker) to follow up with the family every day in between her visits to check up on the family and make sure the child was receiving adequate nutrition and didn’t develop any complications. On our visit 4 weeks later, Ranu had improved from a 110 to 113 mm. Modest weight gain, but proof that Ranu is on track towards weight gain and that the family is putting into practice the tips we’ve given them to ensure that all their children are healthy and happy.

We visited three more houses in this small village where children had had significant weight gain over the past month. At Sursingh and Shada’s home, Asha, had improved from 115 (the borderline of severe to moderate malnutrition) to 125 (the borderline from moderate to normal). Sushila and Raman’s daughter Saraswati had improved from moderate to normal and Gudu’s son Ravi improved from severe to moderate.

Modest success, but an early sign that our work is making an impact in this village for these four families. Multiply that times 500 villages and we’re on track to making a difference in hundreds of lives

Priyanka with Shada and her mother Asha

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