Tuesday 24 February 2015

Is it not better to light a lamp than curse the darkness?


A question we have been asking for at least the last five years: what can doctors do on social determinants of health? Not least, I posed this question when accepting election as President-elect of the World Medical Association. I finished my speech with a quote from Ghandi. Dr Jitendra Patel, (now immediate past-) President of the Indian Medical Association, said: I will start a hunger strike and won’t finish until you come to Ahmedabad. We will take you to a tribal area and show you what we are doing to improve the lives and the health of tribal people. People, that is, who have been socially excluded from the mainstream of Indian society and live in great poverty.

I had to go to check on Dr Patel’s state of nutrition. Indian hospitality certainly enhanced mine.

Gujarat is not one of the most populous Indian states – population “only” 60 million; Uttar Pradesh is 200 million. About a three hour drive from the big city of Ahmedabad, near the Pakistan border, is the Virampur area of the Banaskantha District. Getting there was an ordeal of embarrassment and gracious hospitality. At four stops organised by local branches of the Indian Medical Association we were greeted by dancers, drums, pipes and banners saying: Welcome to President-elect of the WMA. There followed garlands of flowers, shawls draped round the neck, and a slight sense of disbelief on my part that this could be happening.

At Virampur, we were part of a ceremony of opening a new multipurpose facility to aid the work of the Samvedana Trust  in improving the lives and the health of tribal people in the area.



The work began when Ketan Desai, also based in Ahmedabad, was President of the Indian Medical Association at the beginning of the century. He proclaimed the Ghandian slogan: let’s go back to the villages. Dr Jitendra Patel picked up the challenge and began with medical camps ‘under the Banyan tree’ in the tribal area of Virampur. He and his willing colleagues voluntarily treated the illnesses of tribal people from 42 villages in the area. What began with medical camps and on the spot treatment of disease grew. Over a ten year period from 2004, more than 40,000 tribal, and other poor, patients were treated – not at their expense – including over 11,000 operations at a nearby hospital, or in Ahmedabad.

Medical care to the under-served is vital and filling a gap, but as we said on the CSDH: what good does it do to treat people and send them back to the conditions that made them sick.





Note the goat sharing this woman’s front room.

These doctors went further and established the Samvedana Trust. A key figure is Dr Jitendra Patel’s older brother, Hasmukh Patel, social worker, social activist, and all-round good person. He lives simply in the tribal area on the site of the new building.

One among the many reasons, including prejudice and discrimination, for the marginal existence of the tribal groups here was the dry parched nature of the landscape. Hasmukh Patel, and the Samvedana Trust, were instrumental in establishing a system of 90 ‘check-dams’ to capture the water from the surrounding hills. With irrigation, agriculture is being transformed and migration to seek work has been reduced.




The Trust is actively involved in education, in helping gifted children to go on to further training, in promoting handicraft production as a commercial activity, and in generally promoting community development.


One of the lessons I have been taught in India is that government activity is central to improving the lot of the vast population of the nation’s poor. But so, too, is civil society. With an Indian population of 1.2 billion (in the 2011 Census) it is hard for any government to reach into the remoter corners of tribal areas, quite apart from issues of endemic corruption. An inspired and inspirational civil society organisation such as the Samvedana Trust can be transformational.

Working together to improve lives

I was back in Gujarat last weekend visiting street vendors who are members of SEWA – the Self Employed Women’s Association. It was nearly ten years since I visited with the WHO Commission on Social Determinants of Health (CSDH). After that visit I wrote:

I can picture the lives of the vegetable sellers of Ahmedabad from the outside, as they sit on the streets of the market area in the sun and the monsoon rains, with a small pile of vegetables on the rag in front. I cannot begin to understand how it feels from the inside to live the life of one of the poorest, most marginalised women in India. You start with some significant social impediments: you are poor, from a scheduled caste, you had no chance of education, and you are female. The only employment you can envisage is what your mother did: become a vegetable seller. This means you have to borrow money at usurious interest rates to buy your vegetables, pay inflated prices to the middle man in the wholesale market, deal with police harassment as you sit on the road side, and worry what to do with the children while you earn your few rupees. On the morning of my visit an elephant swaying through the market was simply one more hazard.

On this latest visit, Mirai Chaterjee, a leader of SEWA and a member of the CSDH, took me back. The street vendors in this area, the women at least, are members of the union, SEWA. Mirai introduced me to the local leader. She said (in Guajarati) that she remembered me from ten years earlier. Goodness. How come? This is not exactly a tourist attraction, and they don’t get so many outsiders come to visit.

Mirai is the one on the right


This woman was a street vendor as was her daughter. But the next generation? They are getting educated and do not want to go into the vegetable market. It is tempting to believe that the childcare SEWA provides is a significant step towards education. We know from evidence elsewhere in the world that enrolment in pre-school education is a significant predictor of educational success.





Interesting. These women are Dalit, outcastes. They have presumably married other Dalit for generations. But caste is not destiny, or should not be. Give the children the opportunity to be educated and they seize it and, presumably, flourish.

There are many other ways that SEWA has been active in improving the lot of its members. The wholesale vegetable market is a prime example. The wholesalers were forcing small farmers to sell at low rates and passing produce on to the retailers at high rates. Large profit for them; hardship for the street vendors. SEWA, against opposition from the, largely  male, wholesalers, set up as middlewomen: buying from growers at reasonable prices and selling to retailers with modest profit.

SEWA Bank is an important part of the jigsaw – small loans to street vendors without extortionate interest rates. Health care, insurance, legal representation, housing are all active areas for SEWA and its members.


Inspiring stuff. SEWA shows how collective action by civil society can transform lives.