Colorful Perspectives: Caring for Sick Children in Pune, India
—Rachael Butterfield (Edited by Brigid C. Casellini)
I have always been fascinated with different cultures and international experiences. When I was young, my grandparents traveled all over the world and brought back the most amazing tales of faraway lands. When I was seven years old, they returned from India and I fell in love with the colorful traditional clothing, shiny bangles and stories of rich religious and cultural diversity. Their friend from South India visited one summer and inspired my desire to travel to India even more as she taught us how to wrap saris and shared her encounters in the healthcare field.
Author with nursing student and friend, Sonia John.
As a nursing student at the University of New Hampshire, I became eager to learn about nursing in an extremely different culture and how to integrate these views and lifestyles into my own. In 2010, I was awarded a grant by the International Research Opportunities Program (IROP) to study childhood illness and survival status in the slums of Pune, India. With a population of 1.1 billion people, India has 27 million births each year. Of this number, 1.7 million children die before their first birthdays (IBFAN, 2008). Reducing maternal and newborn mortality is a top priority of the United Nations and is incorporated in the goal to reduce global poverty by 2015.
Acute respiratory infection and diarrheal disease are the most prevalent killers of children under five years of age. In 2009, UNICEF stated that with good care, nutrition and medical treatment, ninety percent of deaths caused by diarrhea and sixty-two percent of deaths caused by pneumonia could be reduced (UNICEF, n.d.). Knowing that utilization of health services is a strong predictor of child survival (Griffith, Hinde, & Matthew, 2001), I decided to research what factors influence families’ access to health care, their knowledge of childhood illnesses and the actions they take to improve the health of their children in the slums of India. I connected with the principal of a nursing college in Pune, as well as a non-profit organization, who introduced me to the Tadiwala Road slum neighborhood.
Bustling crowded markets lined the streets which branched into twisting alleys of homes where I was graciously welcomed to conduct my research. With the help of the nursing professors, graduate and undergraduate nursing students, I interviewed sixty-six families with children five years old or younger about their knowledge of childhood illness and actions taken when their child becomes sick. These families came from two different locations—those in the heart of the slum and those with slightly better living conditions. This experience challenged me to open my mind to the fact that there is certainly more than one way of approaching health issues than I had learned in the classroom at UNH.
Insight from the Slum
Perceptions of health and illness vary from person to person, between families and countries depending on historical, religious and cultural backgrounds. Views also vary based on education and income levels. My eyes were opened wide to the reality of slum life in my first walk around Tadiwala Road. The narrow alleys were filled with homes side by side, each holding at least five people, far more than one could imagine. The resources were slim, one water faucet for each side of the alley and one common toilet for everyone. Most of the women did not work outside the home and did not have the opportunity to finish a high school education. The limited knowledge they have surrounding health and illness is what they see in front of them day in and day out.
Tadiwala Road Slum
Cold symptoms such as cough, runny nose and fever are the most common sickness that kids all over the world get. The caregivers I interviewed, primarily comprised of mothers, aunts, and grandmothers, attribute the common cold symptoms to the change in weather from summer to monsoon season. They experience extreme fluctuations from summer heat to intense rainfall. The streets do not have proper drainage systems or homes adequate roofs to keep the rain from flooding in. The alleys are the children’s play yard, overflowing with water or not. The caregivers recognized that playing outside in the rain or cold leads to symptoms, but did not recognize how these factors, combined with their living conditions, contributed to the increase of exposure to bacteria and risk for infection.
Their knowledge of what causes diarrhea or constipation is more deficient than what they know about respiratory infection. When I asked what causes the symptoms of abdominal pain, vomiting, diarrhea and constipation, more often than not I got blank stares and a reply of, “I don’t know.” If the caregiver thought long enough, the common response was that spicy, sour and contaminated foods along with indigestion could cause symptoms. This answer confused me slightly because to a Westerner, all Indian food is spicy, so spices shouldn’t cause more issues for a child who is accustomed to them. However, I learned not to doubt or discredit the understanding these families have but to respect and acknowledge their thoughts and situation.
The second half of my participants were from families of a higher income and social status who resided in apartment buildings around Tadiwala Road. The income ranged from 1500 – 7000 Rupees compared to the 800 – 2000 Rupees monthly income found in the slum. In general the caregiver had nearly finished high school or graduated, but did not work outside the home. A prime difference I found between the two home settings was the decreased ratio of family members living in a home to the number of rooms. The increase in income allowed for more adequate shelter from weather and environmental conditions, as well as a personal bathroom facility. The privacy and space ensures more sanitation and less spread of germs, nearly impossible to avoid in the slums. These caregivers’ knowledge of symptoms and childhood illness was more in depth than the women of the slum as well. They understood that if a child fell ill it was due to some sort of contamination or bacterial infection. They were also aware that diarrhea could be caused by a decrease in water or nutritious food intake and would treat it at home with increased fluids, fruits and vegetables.
Family Cures
Both groups interviewed recognized the importance of taking a child to be seen by a doctor in a timely manner. Since families in the slum have limited education surrounding symptoms and what can lead to a more severe illness, the first action taken when a child seems sick is to take the child to the doctor. If the doctor is too far away or there is not enough time to get the child there, the caregiver may go directly to the pharmacy to retrieve medications, of which they don’t usually understand the names and implications. Conversely, caregivers living in the apartments recognized that “medicine” is actually an antibiotic targeting the germ causing the sickness.
However, I found the home remedies, which are passed from generation to generation, most intriguing. These include Turmeric, which is a yellow plant related to Ginger. It is used in foods but also to treat symptoms of cough and indigestion. Tulsi leaves and sago, a common food, are boiled with either milk or water to soothe a sore throat or help with congestion. Hot and cold compresses are applied on the back, stomach, head or wherever the child feels ill. Vicks VapoRub is also widely used for cough and congestion. The purpose of each remedy varies from family to family and further emphasizes the need to individualize education and care to families no matter the country or culture.
The Future for Children
According to Save the Children’s 2008 report, “Investing in the health of children is not just a moral imperative. Investing in children means investing in the future health and security of a country” (Schmidt, 2008). After being in India and a densely populated city, I have seen first-hand the cultural and social implications surrounding health care. Assessment of factors that could influence utilization of medical services is crucial in every community, especially the slums of India. These factors include family demographics such as income, religion, knowledge and education level. The gracious caregivers who allowed me to interview them provided me with the insight that knowledge truly does come from personal experience. My findings revealed that the understood cause of respiratory and diarrheal infections is rooted in the daily observations and interactions with surroundings and weather. The varying educational backgrounds and family incomes influenced this level of knowledge about what causes infections and what actions were taken.
When planning interventions to provide more information surrounding acute respiratory infection and diarrheal disease, I observed the importance of using vocabulary and scenarios that the target population can relate to. The women of the slum have completely different experiences and insights than a woman living in an apartment or in the United States. It opened my eyes that there is more than one way to teaching, learning and living. Health care providers need to stay open-minded and creative when designing solutions to reduce child mortality numbers.
A child of one of the participants
The vast array of ethnic and religious backgrounds that coexist in Tadiwala Road, my microcosm of India, awed me. The people that smiled at me, shared their lives, food and knowledge with me taught me to value the incredible diversity that exists in our world. This lesson is most important for me as a human providing medical care to other humans. In our nursing courses we are taught to be mindful and respectful of the various cultural backgrounds our patients may come from. My hope for the future is that health care providers always value the experiences, religious, cultural and social backgrounds people come from and work together with them as a community to improve their access to and utilization of healthcare.
I would like to thank the following people for helping to make this experience and research possible: Dr. Georgeann Murphy, Peter Akerman & the Hamel Center for Undergraduate Research; my donors Mr. & Mrs. Noonan, Mr. & Mrs. Beyersdorf, Ms. Samantha Townsend; my supportive and knowledgeable nursing mentors Dr. Gene Harkless and Dr. Carol Williams Barnard; Professor Achiamma Singh, my foreign mentor, and her faculty, staff and students at the Tehmi Grant Institute of Nursing for welcoming me and helping my research come alive; to all the incredible friends that took me under their wing for three months and made Pune my home; and my family for their unconditional love and support through everything. Namaste!
References
2020. (n.d.). UNICEF - Statistics and monitoring - Millennium Development Goals (MDG) monitoring. Retrieved September 28, 2009, from http://www.unicef.org/statistics/index_24304.html
GRIFFITHS P, HINDE, A and MATTHEWS, Z (2001) Infant and Child Mortality in Three Culturally Contrasting States of India. Journal of Biosocial Science (2001), 33:4:603-622
The International Baby Food Action Network (IBFAN). INFANT HEALTH AT RISK IN INDIA: 2008 INDIA REPORT REVEALS DISMAL STATE OF SUPPORT TO WOMEN FOR BREASTFEEDING, from http://www.ibfan.org/site2005/Pages/article.php?art_id=574&iui=1
Schmidt, A. (2008). Save the Children UK : Online library. Retrieved September 28, 2009, from http://www.savethechildren.org.uk/en/54_5700.htm
Copyright 2011, Rachael Butterfield
