My Internship at the Naandi Foundation

Okay so no matter how hard I try, I just don’t think I will ever be a consistent blog writer. My goal before the program began was to write brief updates weekly, but deep inside I think I knew that would not happen…and it hasn’t. I tend to overbook myself and have found that between working, programming, traveling, touring, socializing, and just living, I am constantly busy here. And I think that you all would rather that I be out experiencing India than being inside at my computer…so I hope you understand. At the same time, this blog is waaay over-due. I’m backtracking significantly to the beginning of December to discuss my internship—how it came to be and what exactly it is that I’m doing….

As most of you know, my undergrad degree is in psychology, yet I also have a strong interest in public health. After graduating I looked for a job where I could bridge my two interests, and I found one. I had an incredible opportunity to work for Brown University and Syracuse University in Rochester on a large-scale behavioral health intervention program in a low-income community. Although the focus was HIV prevention, we “intervened” in other health-related behaviors too, and I learned a great deal about the overlap of psychology and public health. While I was exploring the direction I want to take for grad school and my future career, I came on this fellowship program. I hoped that working in two different countries with two different internships would help me narrow in on my focus yet provide the global perspective that I wanted…and thus far, it has.

Upon settling down in Hyderabad, I went on many “interviews” with different non-governmental organizations (often synonymous with non-profits) in order to find the best match for an internship. I met with Save the Children, Public Health Foundation of India, CARE Foundation, Health Management and Research Institute, Catholic Health Association of India, LEPRA Society, and Naandi Foundation. Although I was frustrated that my internship was taking a little longer than expected to begin, in the end, having the opportunity to meet with so many interesting people, learn about important and worthy organizations, and have the chance to choose among them where I wanted to work was really a positive experience. 

Through the LEPRA Society my fellow intern Sarit and I shadowed a doctor at an HIV, Tuberculosis, and Leprosy clinic. It was a fascinating experience. It was in a typical Indian open-air, run-down building with dirt, dust, and peeling paint. The one “patient room” consisted of a desk, a couple of old chairs, a “bed” (aka table) in the far corner with no sterile sheet or towel on it, and an old dusty bookshelf lining one wall. There was a chart on the wall listing this year’s prevalence of TB, HIV, leprosy, and a few other diseases. There were no gloves, masks, sink, nor sterile equipment/instruments. Equally noticeable was that there was no patient confidentiality. The two of us sat there in the doctor’s office as patients came in one by one and he explained to us in detail, and right in front of them, their unique cases. There was even another man in there taking pictures of the patients (and us). We felt like medical students, and thoroughly enjoyed the opportunity to see and learn about Leprosy and TB in such detail. Even so, I still felt uncomfortable by the situation, thinking about how this would never fly at the clinic I used to work at. The doctor even gave a couple people shots in the rear end…right in front of us! We did not have masks or gloves on…nor did the doctor. Despite his pleas not to be concerned, I discreetly covered my face with my scarf as TB patients coughed two feet away from me. He told us in his forty years of working there, he only contracted TB twice and leprosy once…oh NO BIG DEAL! But for those of you who are getting increasingly concerned as you read this, I will get a TB test in Israel just to make sure I am not carrying the virus. Although this internship could have proven valuable, I opted for another position more in line with my interests in maternal and child health.

The patient room at the leprosy/TB/HIV clinic

 

Ultimately, I accepted a position at the Naandi Foundation, and I am certain that it was the right choice. Naandi has many different initiatives that fall under the categories of Safe Drinking Water, Sustainable Livelihoods, and Child Rights. It is a massive NGO in India (top 5), with offices all over the country and five in Hyderabad. I am working for the malnutrition, or HUNGaMA, team, which falls into the category of Child Rights. HUNGaMA in Hindi means “ruckus,” and Naandi is hoping to stir up attention, or cause a ruckus, around the horrific malnutrition problem in India. I have been interested in studying malnutrition with urban, underserved populations in the US so I knew this would give me exposure to a field I might pursue in grad school. My supervisor is also a superb mentor…she is knowledgeable, passionate, determined, and wonderful to work with. In fact, after meeting her, I knew that Naandi would be the best choice for me.

            In the beginning, I went on several field visits in Hyderabad to see Naandi’s programs in action and learn how they interact and build on one another. I visited Naandi Community Water Services, which is responsible for water plants set up around the country that purify dirty ground water into safe, drinkable water for underserved populations at a very low cost. It was interesting to see the entire process—from water collection in the pipes, through the various tanks and filters, to filling the bottles and delivering them in the trucks—as well as to learn about the planning and politics behind it.

Naandi Community Water Services

Filling the jugs with clean water to be delivered to homes

        I visited Naandi’s Mid-day Meal Project kitchen, which is responsible for preparing meals for children at 900 schools in the area. The Mid-day Meal program is a government-sponsored initiative to serve a hot, healthy lunch to hundreds of thousands of school children all over the country, with hopes that the program will increase enrollment, attendance, and retention while simultaneously improving the nutritional status of children in primary school. There are 26 large-scale (and I mean, massive factory-like) kitchens in India and there are two in Andhra Pradesh, the state where I live. Unfortunately, I was not allowed to take pictures inside the kitchen, but below is one of the children at one of the school's enjoying the lunch provided by Mid-day Meal. 

Children eating lunch through the Mid-day Meal Program

        I also visited a handful of Naandi’s various school programs. The best part of these visits is getting to see and play with the wonderful, adorable children who constantly tug on my sleeves and pull me in every direction to play. There are many creative school initiatives under way to help prepare school-readiness for the little ones, increase attendance and retention, maximize learning, and contribute to a higher graduation rate from high school.

Children in Naandi's Early Childhood Education Program

     
            Lastly, I visited two, urban Anganwadi Centers (AWC). AWCs are another government initiative, which provide, in theory, six main services: supplemental nutrition, pre-school education, immunization, health check-ups, referral services, and Nutrition and Health Education (NHE). I am particularly interested in learning about the role of the AWC in pre and post-natal care and their impact on malnutrition and the prevention of corresponding diseases. Unfortunately, however, there are many flaws in the AWC system and corruption contributes highly to its dysfunction. Part of Naandi’s efforts is to address these underlying issues.

The preschool children at one of the urban AWCs

When I began at Naandi I read everything under the sun on the topics of malnutrition and the corresponding diseases, infant and young child feeding practices, and pre and post-natal care (specifically the critical role of breastfeeding). I read reports, websites, manuals, handbooks, journals, and articles to begin to understand the essential issues, policies, opinions, programs, and solutions surrounding the problem. I learned that malnutrition is estimated to be responsible for one third of all child deaths around the world and 11 percent of the total global disease burden. According to USAID, more than 3.5 million children under five years old in developing countries die because of undernutrition. Unfortunately, it is a condition that contributes to irreversible consequences if not prevented or treated within the first 1000 days of the child’s life—that is, the time between conception and the child’s second birthday. Children that are malnourished during this time face stunting in height, mental impairment, higher vulnerability for diseases, increased risk for mortality, poorer academic performance, and lower productivity and incomes in the future. Consequently, the effort is focused primarily on the health and behavior of the mother before and after childbirth. Once the child is two years old, the major damage is considered done.

So this brings me to my work as an intern at Naandi. Two of my projects include helping to design questionnaires for a large-scale data collection project. One is on infant and young child feeding practices in the rural villages. The goal of this is to build a solid understanding of consumption behaviors and exactly what the mother is consuming during and after pregnancy, as well as what she is feeding to her child in the 0-59 month age bracket. Then, nutrition and behavior programs can be refined and better designed to be more applicable and relevant. The second survey I am designing will be used to collect feedback and evaluation on the AWCs, to determine the reality of the services provided by the AWC, and to assess the health of the mother and child, again in the rural villages. This questionnaire will serve as a “report card” to be administered annually throughout the country in order to gain consistent statistics on the use and opinions of AWCs by the mothers and children who visit, and ultimately to pitch to the government the importance of refining the whole system.  The third large project is to prepare a report evaluating preexisting behavior change techniques/methods that have been effective in implementing change among feeding practices for children in the first 1000 days of life in developing countries. I am really busy there—and at times, overwhelmed—but I am fortunate to have landed an internship that is helping me to gain the exact skills and knowledge that I hoped for. 

Field Visit to Rural Villages in Sheopur

When implementing programs to help rural communities, it is critical to gain firsthand experience observing how they live. If possible, it is important to stay for extended periods of time to really pick up on the nuances and pay close attention to the behavior, communication, and lifestyles. This is the key to understanding the real needs of the people, which is why my supervisor chose to live in a rural village for 14 years while pursuing her career in social justice. Last week I had the opportunity to do field-work in a rural village called Sheopur, in the northern state of Madhya Pradesh. I took a 23-hour train ride with my coworker, and then a five-hour cab drive to reach the village. Although five days is by no means enough, it was a valuable experience and an eye-opening opportunity.

With two coworkers from the HUNGaMA team and my supervisor

In Sheopur's HUNGaMA office with the local Field Coordinators

 

           Naandi’s HUNGaMA team set up a program in Sheopur a few months back to address the health, nutritional status, and behavior of the women and adolescent girls in the villages. We went to monitor progress, meet with the team that lives there implementing the programs, and visit AWCs in each of the villages to observe and collect data. In all, I visited about 15 AWCs, which really helped me develop a strong understanding of the reality of the system—and ultimately, how ineffective it is. The most essential items—such as scales, vaccines, fortified food, and health education posters—were missing from most of them. Nearly all were closed when we arrived, even though they were supposed to be open. They were filthy and not maintained and clearly not suitable to deliver healthcare; they really highlighted the severity of the current system. We met with Anganwadi Workers—the women from each village who run the centers and are supposed to carry out the six services mentioned above—as well as with different community members, pregnant women, and children. I saw everything I had been reading about and I had the opportunity to directly speak with the people involved.

An Anganwadi Center--one of the larger and "better" ones

Meeting with some of the Anganwadi Workers and women in a tribal village

Being the first white person they had ever seen, I was greeted with awe, admiration, and confusion. I even had a trail of about 20 people following me half of the time that I walked anywhere. I am used to the staring in Hyderabad, since there are very few other foreigners, but this was a whole new level. The state border guards were so thrown off by seeing me in the car that they held us up for questioning, thinking I was being trafficked. My coworker told me that the villagers get really excited to see foreigners (even my Indian coworkers are considered foreigners) because they think that this means change is coming and things will be better for them. I hope this will be the case. I hope that Naandi’s programs will have positive impacts on their health and wellbeing. Unfortunately, though, the problems are massive and complex. There are so many issues that need to be addressed and NGOs, the government, and public and private institutions all have their own strategies and often competing opinions on how to “fix” these problems. And ultimately, are we really fixing anything or just interfering with a system that works in its own dysfunctional way? I can’t help but think of a prominent theme in Shantaram (see my earlier blog from when I first arrived in India). Roberts writes, “are we ever justified in what we do?...When we act, even with the best of intentions, when we interfere with the world, we always risk a new disaster that mightn’t be of our making, but that wouldn’t occur without our action. Some of the worst things…were caused by people who tried to change things.” I like to hope we’re doing good. If we’re saving lives, improving health, decreasing disease…isn’t this a positive change? Isn’t it for the better?