Tuesday, December 31, 2013

Saturday, November 30, 2013

HIV community groups & networks demanding for high quality TB services – let the dream come true

WORLD AIDS DAY 2013 - Experiences of Universal Health

In the recent International Congress of AIDS of Asia-Pacific/ICAAP in Bangkok I couldn't find traces of concern around HIV-associated TB deaths except few ad-hoc basis discussions on HIV related co-morbidities with TB being a small component. The speakers and participants across the Congress spoke volumes on rights, stigma, discrimination, legal issues, access and mobilization but kept mostly quiet on the burning TB/HIV issues of the Asia-Pacific regions.

The statistics of South-East Asia[1] say, every year more than 50,000 people die due to HIV-associated TB, less than 40% TB cases know their HIV status, less than 40% PLHIV get screened for TB and access of PLHIV to INH prophylaxis is more than negligible.

Demand for newer diagnostics for rapid diagnosis of TB/DR-TB was not heard in the voices of community networks who otherwise made their presence strongly felt across ICAAP.

A prominent member of Asia-Pacific TG network told me, ‘The problem of TB lies in your overall poor advocacy.’

A known friend of the PLHIV network of an Indian state commented, ‘I am really not bothered much about HIV now, but TB scares me hell of a lot, almost every time.’
‘Why don’t you discuss about TB within your group?’ I asked her.
‘I really don’t know what to say except cough for more than 2 weeks.’ She replied pessimistically.

The ICAAP experience made of aware of the fact that we are failing miserably to sensitize people, providers and policy makers on TB and its implications in the background of HIV. It is a grave problem and we must find the solutions.

Limited sphere of advocacy where the advocates don’t really want to venture out of their comfort zone is a big issue in TB. As far as international conferences are concerned the advocacy efforts, in true sense are yet to cross the boundaries of the World Lung Conferences.

Working with HIV community networks might be highly challenging to many TB professionals and advocates, but the fact is 'need for appropriate TB care' is maximum with those networks. When mobilization is their operational expertise these networks need proper guidance to know the right path for consolidating their mobilization and demand generation activities on TB. That’s exactly where we are repeatedly failing to produce any impact.

It is important to bring TB in the agenda and action plans of the international, regional, national and local level HIV community networks (Sex Workers, IDUs, MSM, TG and PLHIV). Let community people speak freely and firmly about their TB problems together with HIV and demand for health facilities enabling rapid TB diagnosis and early treatment. Let there be stronger demand from the community groups for ready access to 3 Is (Intensified TB screening, INH prophylaxis and Infection Control), ART for all HIV-infected TB patients and combined screening of the pregnant mothers for TB and HIV.

TB/HIV collaboration in its true sense can only happen when HIV community groups and networks will play their advocacy cards of TB and HIV on the same table to ensure the right placement of the right package of services for them.

This is the high time we, the not-so-visible TB advocates in the AIDS Conferences, facilitate the process, with utmost sincerity and dedication.

Sugata Mukhopadhyay
Universal Health

[1] Global TB Report 2013

Violent love story of a sexy disease and an unsexy disease – We need to find its end, forever

WORLD AIDS DAY 2013 - message from Universal Health
Being primarily an air-borne infection TB has lost the glamour of a ‘sexy disease.’ But the naked truth is, TB is not selective as HIV and can affect anyone in the society. Unfortunately, those infected by HIV have greater chance of TB infection or active TB disease from a latent infection. The intimacy with the sexiest disease on earth makes TB more noticeable over last couple of decades. And in today’s world Drug-Resistant TB has already spread the dread across the globe the way HIV did decades back before the emergence of ART.

The fact is, the love-story between a sexy disease and an unsexy disease is still going strong. Both the diseases carry tons of stigma. While HIV looks for specific openings like unprotected penetrative sex, needle/syringe sharing and pregnancy, delivery & breast-feeding of an infected woman to trigger and maintain its transmission, TB has the potential to hit anyone, particularly those lying within the territory of poverty and marginalization with poor access to health services. 
Actually, both the diseases, most of time target the same groups of people – poor, illiterate, living in unhealthy living conditions, having limited livelihood options that often lead to migration or sex work or trafficking, injecting drugs as the last resort of poverty-struck recreation and those having no/inadequate access to services due to various reasons including those identifying them in different gender.

Once HIV manages to get the entry into the body, it makes the things easy for TB to show its sting. Similarly TB boosts up HIV in its progression to AIDS. 

Where will you find such violent and virulent loves on earth ? 

 Most of the people infected by HIV get killed by TB.

TB is an old traditional killer and it kills more when it makes love with HIV.

Ideally, all persons with known HIV positive status should have sound knowledge of TB so that they can demand and present for TB screening on slightest doubt. Ideally, rapid and new diagnostic techniques should be in place for early diagnosis of TB among HIV infected, affected and vulnerable population groups. Ideally, all the TB affected persons should be offered HIV counseling and testing services. Ideally, all the HIV-infected persons should have access to prophylactic services of INH and CPT. Ideally, all HIV-infected TB cases should be put on ART without waiting for their CD4 results.

Ideally, TB and HIV professionals, TB and HIV program managers, TB and HIV healthcare providers, and TB and HIV policy makers should have free, frequent and unprejudiced interactions at all levels, national, province, district and sub-district.

Ideally, whenever there is a talk/discussion/debate/seminar/conference/workshop/exhibition on HIV, TB should be the integral part of that and vice versa.

How much we have internalized these ideal conditions which mostly exist in the documents? How much we are geared up to create those ideal conditions? How strong is our partnership to make those ideal conditions happen in reality?

After all ‘ZERO HIV DEATH’ without stopping TB sounds like a fantasy.

Let’s no more fantasize and get into some real action to disrupt and terminate the violent love-story of a sexy disease and an  unsexy disease, forever.

The time is right here.

Sugata Mukhopadhyay
Universal Health

Sunday, September 1, 2013

The stolen bag of gold

The moment I stepped in the office I figured out something grave had happened. Biman was on his desk with an extremely worried face. Kanak was silently weeping in front of him as if he fell into some serious trouble. Bharat, the driver of our polio surveillance unit stood up hurriedly from his seat when he saw me making my entry into the office.
‘What happens?’ I asked them.
I was equally surprised to see Kanak back. He left for Lucknow yesterday. How come he has returned so early? Generally he comes back from Lucknow after 4 - 5 days. Why the hell the fellow is breaking in so much of tears?
‘Sir, there is a big problem.’ Biman’s comment carried a strong sense of concern.
‘What is that?’ I took my seat by that time, ‘What happens to Kanak? Why is he back so early? Is everything fine with him?’
‘Kanak has made a big blunder, Sir.’ Biman gave his reply in a hopeless voice.
Kanak was hired to transport the stool samples of the AFP (Acute Flaccid Paralysis) cases to our regional laboratory located in Lucknow.
All stool samples collected from the AFP cases are tested in the lab to know if those samples have Wild Polio Virus (WPV) or not. If WPV is detected in the stool sample, the paralysis is caused by polio, if not the paralysis is caused by diseases other than polio.
WPV is responsible for polio in children and causes permanent paralysis of their limbs. The paralysis is incurable and irreversible. The affected child becomes crippled for the rest of his/her lives. Polio is a disease without cure.
But the WPV can be eradicated which means the deadly virus can be eliminated from the earth forever. Most of the countries of the world exterminated polio from their soil but few countries including India still harbour WPV. We are putting our best efforts to eradicate polio from our country.
‘What blunder?’ I exclaimed.
‘The box having the stool container inside has been stolen from Kanak’s custody in the train.’ replied Biman in utter dejection.
I was completely shocked.
 ‘But how? How could Kanak be so careless?’
‘That’s what I was telling him Sir. He didn’t take proper care of the box in the train. Somebody must have picked it up taking fully the advantage of his callousness.’
Kanak, all on a sudden, started crying loudly, ‘Believe me Sir, I was always alert in the train. I was traveling in the general compartment as I didn’t have reservation and somehow managed to get a seat over there. The box was on my lap throughout. I dozed off in the journey little bit. The box was picked up during that time. When I woke up I couldn’t find it. I asked everyone in the compartment including a cop, but nobody was able to give me any clue about the box.’
‘Stop crying Kanak. I very well understand the trouble you had gone through.’ I intervened, then asked Biman, ‘How many more days we have to collect the additional samples of stool from that paralytic child? Biman, would you please find out?’
‘Sir, our bag of gold is stolen. It is an irreparable loss. I don’t think we have much time left to collect the additional stool samples. Please let me check from the case investigation report of the child.’ Biman sounded absolutely frustrated.

Bag of gold. That’s exactly what we refer to the stool samples that are collected from the paralytic children in the polio eradication project.
Polio is a disease where a child develops sudden onset paralysis of his/her lower limbs (sometimes, upper limbs as well). Interestingly the paralysis is a loose one and the crippled limb hangs from the body like a dead branch of the tree. We have a special name for this kind of paralysis – Acute Flaccid Paralysis or AFP. Polio affects mainly smaller children, but sometimes it doesn’t even spare the older lots.
The Wild Polio Virus (WPV), that we mentioned in the earlier part of the story enters into the human body through contaminated food and water, subsequently sails into the gut, multiplies in millions and finally gets out of the body through the stool. A polio affected child discharges WPV in maximum number in his/her stool during the period of the first two weeks from the onset of the paralysis. If you collect the stool samples of the paralytic child particularly during that time and test it, there is maximum chance of detecting the virus in the stool and thereafter, you can easily confirm your diagnosis of polio in the paralytic child. In case the same stool sample doesn’t show any trace of WPV in it, you can confidently say the child has developed paralysis due to some other illnesses but not due to polio.
So, timely collection of stool, that is within two weeks of the start of paralysis in the AFP-affected child is the most important thing to confirm if the child’s paralysis is caused by polio or not.
Sometimes, due to delayed reporting of the paralytic child, his/her stool sample can’t be collected within that two weeks’ deadline. That reduces the chances of detecting the virus in the stool of the paralytic child, as the excretion of virus in the stool drastically lessens after the deadline of two weeks.
The golden rule of polio eradication project says, ‘Search extensively for all the AFP affected children in the community, detect them early, preferably soon after the start of their paralysis, collect their stool samples by all means within the two weeks’ deadline, and ensure in this way that you haven’t missed to diagnose a polio affected child in your area.’
This vigilance work of detecting the AFP cases in the community is the most crucial thing in the polio eradication project. In public health terminology we call it polio surveillance. Missing an AFP affected child and subsequently failing to collect his/her stool samples during the period of first two weeks after the start of paralysis denotes you are not sufficiently alert in your AFP vigilance activities. That further means, we fail to know which AFP case is due to polio, which is not.
Without a sensitive vigilance system of timely AFP case detection and stool collection, polio eradication efforts remain weak and ineffective.
Our bags of gold were collected on 6th and 8th day of the paralytic onset of the child. We further calculated from the case history of the same child that today was actually the 11th day, and we have only 3 days left to collect the additional samples of stool to keep the case within the parameter of ‘timely reported’ category.
I cancelled all my routine activities and rushed to the village of the child to collect the stool samples. The child’s residence was in the remote village of Banmankhi block. When we reached the house a big surprise was waiting for us over there.
The child had been already transferred to her Nani’s (maternal grandmother) place in Bhawanipur block. We noted down the address of the Nani’s village and made immediate move towards the new place.
Crime, big and small is a common event in Bhawanipur block. We were repeatedly told by the block officials not to travel in the block, especially after the sunset.
But we were desperate to collect our ‘bag of gold’. We had no option left.
  We reached Bhawanipur in the late afternoon. The route connecting Banmankhi with Bhawanipur blocks was tortuous with a horrific strip of road filled with innumerable pits of various sizes that consumed a lot of our precious time.
The next challenging task in Bhowanipur was to locate the exact place where child is currently residing and reach there at the earliest.
We took the help of the local Primary Health Centre (PHC) of Bhowanipur. The Medical Officer of the PHC Dr R.P.Singh was gem of a person. The moment he heard our tragic story of stolen ‘stolen gold’ he took no time to jump into our jeep to accompany us in the most daring ‘stool collection mission’. He took with us his right hand man of the PHC, Mr Arjun Mishra, one of the Health Educators. Arjun Mishra knew every nook and corner of the block like the palm of his hand. Being a seasoned local man he was also a safe guard against any possible criminal threat en route.
Thereafter, we landed into the problem number three.
Polio virus is a funny virus. It can only survive in very low temperature. Slight increase of temperature in its environment can destroy the virus in no time. After collection, the stool samples should be kept inside the frozen ice so that the virus, if present in the stool samples can remain viable there. The stool samples are sent to the lab with adequate and proper ice packing to keep the required temperature intact throughout the shipment process.
Whenever we go out to the field to collect our ‘bag of gold’ we always carry a vaccine carrier with four frozen ice-pack inside. After collection the stool containers with the stool samples inside are placed within the inner space of the vaccine carrier that is surrounded by the four ice-packs and brought to our polio field office; there after transferred immediately to the deep freezer of the office and kept till they are transported to the regional lab for testing to detect the wild polio virus in the samples.
If your air conditioning system for the ‘bag of gold’ is not proper, your gold might not remain gold till the end, channelizing all your hard efforts into the water.
It was middle of the summer. When we checked our ice-packs they were half melted. The chances of replacing them with frozen ice packs from the Bhowanipur PHC were bleak.
There is a need of uninterrupted electric supply to freeze the ice-packs adequately inside the refrigerator. But that always remained a dream in a place where power cut for hours was the most common phenomena.
Dr RP Singh had finally come out with a solution of the acute problem. We stopped the jeep at a rural ice-cream factory on the way and bought a big chunk of ice to fill up the vaccine carriers to freeze our half-melted ice-packs.
We reached the village on the verge of the sunset and somehow managed to locate the child’s house with the help of some kind hearted villagers.
Fortunately, the child was present in the Nani’s house with her mother.
‘We have to hurry up a little bit.’ Arjun Mishra put an instantaneous alert on us, ‘the place is not safe after the evening.’
And then emerged the challenge number four of the day.
The mother informed us the child has become severely constipated, so ready stool sample is very unlikely. We need to wait. But how long?
‘Give the child some milk and biscuits. That can produce some stool.’ suggested Dr RP Singh.
‘The child is not taking her food properly since her illness.’ complained the mother. She had already been giving us frequent suspicious looks by that time.
Why these guys are so much after my child’s stool?’
How did the poor woman know that it was not stool but the bag of gold for us?
Worries were clouding in Arjun Mishra’s face with time. He was much more concerned about our safety than collecting stool from a constipated child.
The child was given milk and biscuits but she refused them on the spot. All attempts to feed her had miserably failed.
I suddenly remembered my jeep has a flatus tube which can be used to collect stool from a constipated paralytic child. Bharat immediately brought the tube.
We told the mother that we would make the child pass stool with this tube which will be inserted in her anus. Her suspicion became deeper and she refused our proposal straightway.
‘Let me try with my little finger.’ Dr RP Singh again came forward to suggest another option to get out of this unexpected crisis.
He convinced the Nani (maternal grandmother) first and thereafter the mother and other members of the family.
When the child passed stool, it was half past eight. My happiness knew no bounds irrespective of Arjun’s Mishra’s repeated words of caution, ‘We are very much late Sir. We must leave now. This is not at all a safe area to travel at these hours.’
And we faced the fifth and final challenge of the day, on our way back to Bhawanipur PHC.
After about fifteen minutes of leaving the village with a successful ‘stool collection’ mission under our belt, when we were enjoying the bumpy ride on the uneven and constricted village road, about 10-15 masked horse-riders blocked our way. We just couldn’t figure out how and wherefrom the bandits appeared so fast to stop our jeep.
They were carrying guns, and some of them were AK 47 – our jeep’s strong headlight made them clearly visible.
‘That’s what I continuously feared about.’ I heard Arjun Mishra’s fretted voice.
‘Don’t look at their eyes when you talk to them and for God’s sake don’t argue with them if you really value your life.’ cautioned Dr Singh.
One of the horse riders waved his hand to tell us switch off the jeep’s headlight. Bharat helplessly reciprocated.
Three of the horse riders gradually neared our jeep. Their silhouettes looked no less than haunted walking spirits under the clean moonlit sky. One of them pointed his finger at us to get out of the jeep.
‘Are they going to shoot us?’ I murmured.
‘I hope not.’ Dr Singh pacified me.
When we disembarked, two of the horse riders were already on the ground from their horses. I could see their third companion targeting his gun at us on the horse. My heart almost stopped that moment.
We were very much within their firing range. It is just a matter of pressing the triggers of those deadly killing machines to put the complete full stop to our lives.
‘Who are you and where are you coming from?’ one of them asked harshly.
‘Let me handle them. None of you should respond to their queries.’ mumbled Dr Singh once again.
‘We are from the polio department. We went to the near- by village to see a paralytic child.’ he replied in extreme politeness.
‘Search the jeep. If anyone tries to play smart, don’t hesitate to shoot.’ instructed the same person to his fellows.
Two of the men got into the jeep. After sometime, they came out with the vaccine carrier which had our most valuable ‘bag of gold’ inside.
I felt I was equally worried about the most valuable stool sample which had been collected after a whole day’s inhuman efforts.
‘What is there inside this box?’ asked one of them.
‘Stool sample.’ replied Dr Singh smoothly, ‘We collected from the paralytic child.’
‘Open the box.’
Dr Singh looked at me, smiled and knelt down to open the box.
‘Please have a look inside.’ he told the bandits after he opened the vaccine carrier.
One of them switched on the torch to look into the vaccine carrier and took the stool container out.
‘What is this?’
‘This is the stool sample as I told you about.’
The man immediately dropped the container on the road. ‘Shit, its stool, damn it.’ he said in utter disgust. His fellows burst into sudden laughter.
I immediately put the container with stool sample back to the vaccine carrier. I just couldn’t afford to lose my bag of gold once again.
‘Why there is so much of ice inside your box?’ the man asked again.
Dr RP Singh gave the bandits a small but solid lecture on polio, stool sample collection, two weeks’ deadline etc etc.
They were probably not ready for a polio session like this.
‘Let them go. They are harmless polio people.’ We heard him instructing his men.
We had a big sigh of relief.
The rest of our journey was eventless except a very special comment of our good friend Mr Arjun Mishra.
‘Sir, your stool sample actually saved our lives today.’
‘Remember, we have to collect one more sample of stool after 24 hours.’ I gave him a mild reminder.
‘No problem Sir,’ Arjun got back to his usual enthusiastic mood once again, ‘We can take hundreds of those samples now. Nobody will dare to touch us anymore.’ 

From the story-book 'Eradicators' by Sugata Mukhopadhyay 

Friday, August 23, 2013

Scaling up of STI services in the third phase of National AIDS Control Program of India


Sugata Mukhopadhyay

Issue: STIs are the major co-factors of HIV transmission. An estimated 30 million of STI episodes occur in India. The third phase of National AIDS Control Program of India targeted to reach about 10 million STI episodes annually.
Project or Activities: Designated STI/RTI clinics increased from 916 in 2008-09 to 1112 in 2011-12. 45 national and 587 state resource faculties from all states were trained on STI management by National AIDS Control Organization (NACO) of India during 2007-08. Those resource persons trained 2224 healthcare providers in 2008, 7511 in 2009, 5224 in 2010 and 6496 in 2011. 7 STI training, reference and research centres were established to augment training and research in STI case management across the country. In 2007, STI Clinics were branded as Suraksha clinic within the National Communication Strategy on STI/RTI Service Delivery. 776 STI counselors were appointed in the program in 2007-08 which was scaled up to 955 in 2011-12. Preferred private providers who treat HRGs in their localities for STIs were identified and trained on national STI treatment protocol, 5744 in 2009-10, 3891 in 2010-11 and 3942 in 2011-12. Pre-packed colour coded STI/RTI kits were provided for free supply at all designated STI/RTI clinics.
Results: 2.6 million, 6.67 million, 8.49 million and 10 million (till Jan’12) STI episodes were treated in 2008, 2009, 2010 and 2011 respectively. HRG members who had been treated for STIs showed gradual increase from 158,973 in 2007 to 632,151 in 2008 and to 1,057,577 in 2009. It was also observed that number of STI/RTI cases in HRGs declined from first to third quarter of 2011-12 by 2.5% though the clinic attendance went up to 18%. During April-June, 2011 38.5 percent of HRG had utilized regular medical check-up services of TI (Targeted Intervention) clinics which increased to 45.9% during Oct.-Dec 2011 showing improvement in health-seeking practices in HRGs. Though syphilis testing has improved but still below 40 percent against the target as country average.
Lessons learned: : India’s experience is one of the most prominent examples of scaling up of STI services through optimal resource allocation and strategic implementation of action plan of STI control.

(Selected for E-POSTER)

Friday, August 16, 2013

Child sexual abuse in India – a situation analysis

Author: Sugata Mukhopadhyay

Background:  19% percent of the world's children live in India, which constitutes 42 percent of India’s total population (430 million). The government estimates that 40 percent of India's children vulnerable to sexual abuse, trafficking, homelessness, forced labor, drug abuse, and crime, so needs protection.

Methods: The abstract aims to do a situation analysis of child sexual abuse in India by collecting relevant information including case-studies through net-surfing, interviewing local NGOs working to protect children and interacting with some abused children. 

Results: The ‘Study on Child Abuse: India 2007’ of Govt. of India sampled 12447 children, 2324 young adults and 2449 stakeholders across 13 states with the following key findings:  53.22% of children reported sexual abuse. Among them 52.94% boys and 47.06% girls. Andhra PradeshAssamBihar and Delhi reported highest percentage and incidence of sexual abuse. 21.90% of children faced severe forms of sexual abuse, 5.69% sexually assaulted and 50.76% reported other forms of sexual abuse. Children on street, at work and in institutional care reported the highest incidence of sexual assault. 50% of abusers were known to the child or are in a position of trust and responsibility. 94% children had not reported to anyone.

According to studies conducted by Civil Society Organization,
·         9000 children estimated to go missing annually
·         500,000 children estimated to be forced into sex trade annually
·         Children form 40% of total commercial sex workers’ population
·         80% of these children found in the five metros – Delhi, Mumbai, Kolkata, Chennai, Bangalore
·         71% illiterate.  

Conclusion: Recent rapid rise of child abuse cases across the country is the outcome of escalating degradation of social values and growing desperateness to make mockery of law and administration. The crisis should be responded with large scale advocacy & social awareness to restore children’s rights and exemplary judicial decisions against abusers. 

(Selected for poster presentation in SVRI Forum 2013 (14 - 17th Oct'13, Bangkok, Thailand) 

Sunday, July 28, 2013


Uchenna Anozie,

Male circumcision (from Latin circumcidere, meaning "to cut around") is the surgical removal of the foreskin (prepuce) from the human penis. In a typical procedure, the foreskin is opened and then separated from the glans after inspection.

This procedure is obtainable in many races of the world and it was on biblical record that circumcision is a sign of covenant between the Israelites and Yahweh. Apart from the Jews other races practice this, especially African races.In the western world circumcision is done at childhood and done medically with anaesthesia in some cases, this medical procedure is safe and sound without any negative impact, and in fact recent discoveries show that circumcised males stand a reduced risk of contracting HIV than the uncircumcised.

Other sources confirmed that women prefer men with circumcised penis than the uncircumcised penis, reason being that the uncircumcised penis has an ugly aesthetic view and often very pointed, well there is no theory that proves to us which penis is better.

It will interest us to know that various races round the world see circumcision as a ritual but today I am going to focus on South Africa where this ritual of male circumcision is taken serious and it is becoming a public health concern because  lot of lives have been lost in this ritual performances while some males have permanently lost their penis or are still battling with a rotten penis due to acquired infections associated with their procedure of circumcision. Also HIV has been a great concern because unsterilized instruments are used during these rituals.

According to inquirerdotnet, Agence France-Presse. Monday, July 8th, 2013. Botched circumcisions killed 30 young men and landed almost 300 more in hospital during traditional initiation rites in a South African province, the health department said Sunday.

The 30 deaths in rural Eastern Cape province occurred during the annual season when young males undergo a rite of passage into manhood.

Ten other youths were hospitalized after being rescued from a forest on Sunday, said provincial health department spokesman SizweKupelo in a statement.

“The ten initiates’ private parts are rotten. They are badly damaged. Their condition is scary,” he said.
A further 293 young men were undergoing hospital treatment for dehydration, gangrene and septic wounds, Kupelo added.

Some had lost their genitals.

Teenagers from ethnic Xhosa, Sotho and Ndebele groups typically spend around a month in secluded bush or mountains areas for their initiation to manhood.

This includes a circumcision as well as lessons on masculine courage and discipline.

Traditional surgeons perform the procedure in the bush, sometimes with unsterilized instruments or lacking in technique.

Botched circumcisions leading to penis amputations and deaths are an annual tragedy.

In May around 34 deaths in two other provinces were reported.

Needless giving more history on these sad events, it has been a regular occurrence in South Africa but the question is what can we do about this public health problem, this is an ugly trend and yet we need to respect people’s culture and tradition.

We public health activists should do our best to convince the south African government to carry out a strong advocacy on safer ways of practicing this circumcision ritual, it will be better off if these males are circumcised as children, not waiting till the grow up to 16 years and above. Also if medical practitioners are involved in the procedure with anaesthesia and sterilized instruments being used, then we can encourage this ritual, but these traditional surgeons are endangering people lives, young and promising fellows. It has been reported severally that people witch hunt their enemies during these ritual by doing a bad procedure on the children of their presumed enemies.

Let us spread this campaign and who knows the South African government might have the political will to face this ugly ritual trend.

Monday, July 1, 2013

Mahila Mandals: Case Studies from Mumbai, India

Sarah Simpson, University of Medicine & Dentistry of New Jersey, MPH-Epidemiology Candidate

Home to more than 18 million people, India’s most populous city, Mumbai, continues to be an attraction for millions looking for a better life for themselves and their families. Migrants from different parts of India, religions and cultures end up in the crowded slum communities around Mumbai. This past winter I had the opportunity to learn about urban health issues in these slum communities along with 20 other students from around the US and the world for three weeks at the Tata Institute of Social Sciences (TISS) in Mumbai.

My project group and I sped around town in rickshaws, trudged through sludge, and dust to study urban health issues in the slum areas of Shivaji Nagar.  Located in the M Ward and home to some of the largest slums in India, about 600,000 people live in this area, which is located near the Deonar dumping ground, a man-made mountain of debris and trash. The health of the urban poor is complicated by many issues ranging from waterborne illnesses to infectious and communicable diseases, and when compounded by inadequate nutrition and overcrowded and poorly constructed living conditions makes for a dire situation for millions of people.

During our first day, we were introduced to the “Mahila Mandals” or women’s groups there are instrumental to addressing these public health issues.  Parts of Shivaji Nagar are plotted slum areas recognized by the government; however they have minimal access to facilities and services provided by the Brihanmumbai Municipal Corporation (BMC). Imagine sharing 28 bathroom stalls (14 for men, 14 for women) with 1,000 other people and as you can imagine they quickly become unsanitary. The breakdown of government services has lead to the organization of community based organizations such as Mahila Mandals.

Instead of using a needs-based or problems-focused approach which would highlight only the worse aspects of a community, we decided to highlight the community’s assets by writing a case study using SWOT (Strengths, Weakness, Opportunities and Threats) Analysis to help us investigate how to best utilize these important community assets. We interviewed 6 Mahila Mandal groups consisting of some registered and unregistered groups and varying in size and number of members.  We concluded that not only do the Mahila Mandals work to solve issues with sanitation, but they also promote immunization of children, maternal and child health education and resolve domestic violence issues. However, their impact is limited mostly due to funding and support from the local community.

At the end of our study, we recommended that the government provide more funding and implement community-based participatory research programs which would allow the communities to identify, support, and mobilize existing resources to create a shared vision of change and encourage greater creativity in solving community issues.2 Community organizations like these groups and community engagement are important for continued public health and social change. Further research is needed on how to best utilize these valuable community assets.

Our internship presentation can be found at: http://prezi.com/i0lbgveimbyc/copy-of-indian-urban-slums/


1. Mili, D. Migration and Healthcare Access to Healthcare Services by Migrants Settled in Shivaji Nagar Slum of Mumbai, India. TheHealth 2011; 2(3): 82-85