Project RISHI (Rural India Social & Health Improvement) » Northwestern’s Summer Trip to Charnia

Challenges in implementing an anemia intervention in Charnia

The Northwestern Chapter has partnered with the village of Charnia, a small village located in the northern state of Haryana in India. Charnia’s population consists of farmers and brick laborers. The farmers are relatively well off, while the brick laborers work in brick factories and live in small brick huts. The laborers have limited access to both basic healthcare and education. Over the past three years, we have been visiting the village every summer to conduct health assessments, run specialized health camps, and establish a primary care clinic in the area. After conducting a thorough needs assessment last summer and analyzing the data we had gathered, we found that approximately 80% of the patients who visited our health camp had low hemoglobin levels and thus were very anemic. When we went to India this August, we decided to focus on reducing anemia in women and children in Charnia.

Going into the trip, our plan was to target around 5 brick zones and run hemoglobin tests of all the women and children in these brick zones who were willing to participate. After establishing who was anemic, we planned on buying and providing a three months supply of iron folic acid supplementation pills, as iron deficiency is the most common cause of anemia. In each brick zone, we would choose a health promoter, someone who we felt was a leader in the community and could encourage the anemic patients to take the IFA supplementation. Our supplementation program would run for 3 months after which we would retest everyone’s hemoglobin levels and determine the effectiveness of our program and expand to the neighboring areas. While we had put months of planning into preparing for the trip for the summer, little did we realize that almost nothing would go to plan. The government bureaucracy along with resistance from the brick owners, as well as the anemic patients threatened to bring our trip to a grinding halt and taught us all some very important lessons.

After arriving in India, we immediately started with our hemoglobin measurements with help from technicians from the Post Graduate Institute, Chandigarh. We didn’t have much of a problem convincing anyone to provide us a prick of blood for the hemoglobin measurements. The data we collected showed that the anemia problem was much more prevalent and serious than what we could have imagined. Almost everyone we tested were anemeic. In addition, all six of the pregnant women we tested were severely anemic with hemoglobin levels below 6gm/dL while a normal level is 12gm/dL or above. The Indian Government has a program in place deliver IFA supplementation to all pregnant women for free through what is called the ASHA program. ASHA workers are supposed to work in their districts and test all pregnant women for anemia and provide IFA supplementation if the women are anemic. Clearly, no one was providing any assistance to the brick laborer population. After tracking down and talking with the local ASHA coordinator and the local AHSA worker who was responsible for Charnia, they told us that the brick factory owners did not allow them to come into the brick factory land to provide IFA supplementation to the women.

After talking with the brick factory owners ourselves, we found that most were hesitant to provide IFA supplementation to their workers because the Government of India had recently started a anemia campaign in which they were distributing IFA supplementation. Recently, newspapers had picked up stories where children had to be hospitalized with stomach pain after taking IFA supplementation. The owners were afraid that if the workers took the IFA and had adverse side affects, they would be held responsible. We finally convinced them that IFA supplementation had a very low side effect rate of around 1%. What most of the owners didn’t know was that the government also provided free 24 hour emergency ambulance service through the National Rural Health Mission. After multiple meetings and numerous reassurances, the owners agreed to let us provide the anemic workers with IFA.

Our next task was to meet with the Civil Surgeon of the Panchkula District, the doctor in charge of all government hospital and health intativates in the area. We needed his approval before we could move on with distributing IFA supplementation. The Civil Surgeon, Dr. V.K. Bhansal, a very busy man, carried two cell phones with him which rang every five minutes. In our meeting, we tried to relay what we were trying to do in the middle of his phone calls. Dr. Bhansal immediately told us that we would not be able to distribute the IFA supplementation ourselves as that would create a enormous medical liability for us. Instead, he suggested that we go through the current ASHA system. He called the ASHA Coordinator and told her to go with us to Charnia and register all the anemic patients with ASHA so that they could be given IFA supplementation. Then, he asked to look at the hemoglobin data we had collected. Upon seeing the hemoglobin levels of the six pregnant women, he told us that they needed immediate care. He told us that we was sending the ASHA Coordinator with us immediately and we were to go to find these six women immediately. The ASHA Coordinator would arrange a ambulance to pick up the women so that they could be taken to the local primary care center, and if needed, the closest government hospital. Although we were apprehensive over trusting the ASHA system with distributing the IFA, realized that helping the pregnant women should be our first priority so we set of at once back to Charnia with the ASHA Coordinator in our car.

The six women were spread across four brick zones and none of the women wanted to come with us. It took the ASHA Coordinator, all of the hindi speakers, as well as some of the local Charnians to convice the women to come with us. Although we had to pick up only 6 people, it took us over three hours after which we headed directly to the primary care center. There, the ASHA Coordinator had everyone’s hemoglobin levels rechecked and most were around 5gm/dL a level dangerously low for anyone let alone a pregnant women. The doctor at the primary care clinic advised them that they would all need to go to the local government hospital, as the primary care center was not properly equipped. The ambulance would provide transportation to and back from the hospital and the care would be offered free of charge. After we told the women about this, they all refused to go to the hospital. They started to argue with us and one women even told us that she didn’t think anything was wrong because we could lift very heavy things and only got a fever once a year. We tried explaining to the women the importance of going to the hospital for both their and their baby’s health. However, none of them really wanted to go and they all just walked out of the primary care center and started walking back towards the brick zones around 10km away. We ran after them and told them we could drop them off in the ambulance, but they were all afraid that we would get them into the ambulance and take them to the hospital against their wishes.

Having the women walk out on us was the low point of our trip. It felt that we were doing more harm than good if we couldn’t even convince the Charnians that anemia was a problem, then why would any one even take the IFA supplementation? The next day, we visited the rest of the brick zones to talk with leaders within each brick zone. They told us that they realized the importance of taking IFA for anemic patients and they would encourage everyone to take the IFA if we could provide it. They also provided more insight into my the women did not want to go to the government hospitals: they said that the doctors at these hospitals usually treat them very rudely and often they have to wait long times without getting any treatment. With the encouragement and reassurance of the locals we started to coordinate with the ASHA worker to start IFA distribution. The next day, we came back with the AHSA coordinator, the ASHA worker, and a doctor from the primary care clinic and distributed a 10 day supply to everyone we had identified as anemic. The ASHA worker agreed to visit every 10 days to keep replenishing the IFA supply.

In the end, we accomplished setting up a anemia intervention, though not run directly through us, was the best we could do given the circumstances and laws in place. In the end though, many of the problems we faced are not going to be solved through short term interventions or any medicines. Long term change will only happen through education about nutrition and anemia. The pregnant women who ran away from the clinic didn’t even think they had any health issues to begin with and nothing we said would convince them otherwise. In the long run, building long term relationships with Charnians and establishing trust with the community, something which will only happen over a long period of time, is the only sustainable way of bringing real change to the community. We hope that in three months, when we revisit Charnia, to retest the anemic women and children, we will see a dramatically improvement in the population and hopefully through our efforts we can continue to build trust and support for our chapter in Charnia.

Article by Chintin Pathak

Originally published at