on "what the hell am i doing"?

so: health education is a load of shit.

well, maybe i should revise that: teaching people to be healthy is the most moronic idea ever.

but with this qualification: so, i'm, uh, gonna be working to run a health education and resource centre in a slum in india for the next few years. but i'm sure this time, i'll get it right where everyone else as failed. because this is going to be different.

yeah, right.

so the deal is that in a month or two im headed back to pune, india to work for the next few years to help get a "health education and resource centre" going and to work there day-to-day. it's with an organization i've been working on-and-off with for the last few years. they started a home for street children, run a program to encourage girls' education in the neighboring slum and now are branching out to do something about health there. tuberculosis, anemia, diarrheal disease and any other manner of preventable morbidity and mortality are pretty huge issues there, and to make things worse, the indian government programs that would theoretically make a huge dent in the incidence of all this are pretty much completely ineffective, simply not providing the services they are meant to provide as their raison d'etre.

but anyways, back to the health education is crap thing. yeah, it's good to impress upon people (and especially small children, but we'll get to that later) the importance of handwashing to prevent the spread of a lot of diseases (by the deliciously poetic (in spanish) cycle of ano-mano-boca). people should know that their diet should include a wide variety of nutrients, and in sufficient quantities.

but i can't teach how to avoid tuberculosis--the best way is really to not know anyone with tuberculosis. covering your mouth when you cough isnt sufficient, because the drops can hang in the air for hours, they don't need to be sucked up directly. and i can't teach you how to not get active tb once you've been infected, since that really depends on your nutrition and general "constitution" for lack of a better word. and teaching people nutrition in a "development" context is really just a joke. i mean, wtf, can you figure out a way to have a balanced diet when your ingredients consist of potatoes, some vegetable oil (that may or may not be fortified with vitamins A and E) and salt (that probably isn't iodized)? trust me, for most people in most of the places where nutrition is seriously lacking, no amount of education is going to make even the smallest difference in their diet, because they're already stretched to the limit of survival.

so basically, the best way to teach people to be healthy is to teach them not to be poor, right? and now that definitely sounds like a ridiculous idea. unless you're a republican and you believe that poor people are just lazy. but anyways, to look further at the example of tuberculosis (which i've been obsessing over quite a bit lately), let's think of the things that structure your risk of dying of tb. first you've got to get infected. let's leave that one alone for the time being (since its pretty much impossible to prevent someone from giving you tb, it's easier to look at it from the point of view of the already-infected person spreading it, rather than someone "catching" it). next, your infection has to become "active". ie, it has to go from a few mycobacteria harmlessly chilling in your lungs to a bunch of mycobacteria going crazy multiplying and punching holes in all manner of tissues and organs. a brief list of conditions that tend to increase the risk of tuberculosis progressing from "latent" to "active":
[from the CDC's "Self-study modules on tuberculosis. Page 8 of Module 1]

so i took the liberty of bolding the conditions that are way more likely to be present in marginalized, and especially impoverished, groups, for pretty obvious reasons. the conditions in italics can in a number of ways be linked to poverty, but i'm gonna leave them alone since they're less relevant to what i generally am working with. the others can basically be either attributed to medical treatments (and previous medical treatments are pretty much completely unknown where i'm working) or "other conditions" that aren't specific enough for me to actually know what's being talked about. but basically there are a few conditions--HIV, previous active TB disease and malnutrition--which are hugely more prevalent in poor populations, especially in Pune. so poor people are certainly more likely to progress to active tb disease once infected than most others. then, they're less likely to be treated at all, and if they are treated, treatment is like to be inconsistent, poorly-designed, poorly-implemented or implemented in such a way as to be completely insulting, or any combination of the above. there are financial and geographic barriers to treatment--medicines are expensive, hospitals are not located in slums and time off from work...well, only if you don't mind not getting paid that day. poor people (in india certainly) are often treated like shit in the hospital, made to wait long hours (8 hours, easily), insulted and generally treated without any human dignity. migrants (a large population in the yerwada slum) are further left out--the hospital signs are only in marathi and english, not hindi, which most migrants speak (english is the language of the educated and the wealthy, and marathi is the state language of maharashtra--hindi is spoken by most people, at least in northern and central india, as well as the language which is "local" to their place of origin). often service is even completely denied because a person is from a "criminal tribe" and thus "addicted to crime"--from birth, apparently. and the DOTS program, which demands that people are "directly observed" in taking their medications, thus ensuring compliance and completion, demands that the patients go to the DOTS office at least 3 times a week, if not every day, to take their medications, rather than health workers distributing medications even near their homes. so yeah, its an uphill climb for treatment. in such an environment, it's hard to imagine many poor people even beginning treatment, let alone finishing it successfully--which then leads to drug resistance. and any active, untreated case of pulmonary tuberculosis is contagious. so if you're poor, not only are you more likely to fall ill and not be treated, but you're also more likely to know other people who have fallen ill and have not been treated, thus leading you to be much more likely to be infected in the first place. it's pretty easy to see how tuberculosis has been relegated to the history books in affluent places, but is still rampant in most poor places, especially where people are highly concentrated.

and so it goes. so basically what i want to do, what i will do, is to interrupt that chain at every point. which doesn't really involve "health education" at all. we have to educate people, yes, to recognize sympoms of tb, but more we need to educate and mobilize them to demand treatment from already-estabilished government programs that theoretically provide free treatment but simply suck at it. we need to break down barriers to treatment, but also treat the conditions that put people at risk--poverty, lack of social mobility, lack of basic services, in essence, the lack of all the "basic necessities" that we learn about in first grade: food, water and shelter. we will be improving health by working to combat prejudice and discrimination and by working for women's empowerment. keeping kids in school through secondary and higher education will lessen their chances of dying of tuberculosis. as it will for most any other disease.

so then, are we actually going to teach? yeah, we will. we will teach people to wash their hands. fine, but to assume that by just pouring in this knowledge will improve anything is ridiculous. that could work with children, but to teach adults and even adolescents to simply wash their hands is treating them like children. there are very specific reasons that most of them have never washed their hands regularly--lack of soap, lack of water, and even that handwashing has simply never been a priority because there are much more immediate causes of morbidity and mortality to worry about. we're probably going to have to give out soap, and fight tooth and nail for more water connections in people's houses.

yeah, we're going to be teaching, but that's just the beginning of what we need to do. we need to provide for a basic level of subsistence sufficient so that they can apply what they've learned.