Tag Archives: accomplishments

Rehydration Unit

In the video, the Haitian child was listless: his eyes were sunken and his shriveled body was limp. His mouth curled, turtle-like, to prepare to cry, but no tears came. A gloved hand, arm hairs poking out, reached for the skin around the child’s abdomen. The hand of the clinician pulled gathered skin to form a sinusoid mound. Then, instead of snapping into place as skin normally does, the mound slowly melted back like silly putty. The words “SKIN PINCH” scrolled across the bottom of the video.

The skin pinch is one of the main diagnostic criteria for testing severe dehydration. In those severe cases in which the body has lost more than 15% of essential fluids, the little fluid left in the body rushes to the skin to cause the counterintuitive effect of swelling. Taped during a cholera epidemic in Haiti, the CDC video was showing how to best manage dehydration. The child had become severely dehydrated from the watery diarrhea that is a common and deadly symptom of cholera infection. By the end of the video, thanks to provision of the best possible treatment, the child was healthy and alert.

This “best practice” is something we are replicating in the slums of Fakir Bagan at Calcutta Kids with the new Rehydration Unit. The Rehydration Unit will allow us to tackle the terrible effects of diarrhea on the children under the age of three in our area. I reviewed over this CDC video to train our community health workers to diagnose and deliver key messages in the Rehydration Unit. One of our four main objectives at Calcutta Kids is to ensure that children age 0-3 grow normally. Diarrhea, the cause of fatal dehydration, is one of the central culprits in preventing normal growth, since it’s been linked to stunting and slower brain growth (1). Over the past six months, Sriya Srikrishnan (the other AIF Clinton Fellow) and I have been working to develop training modules for the health workers, a treatment protocol, and new counseling materials for the Rehydration Unit.

There is no reason any child should ever grow less or die from diarrhea. Yet this preventable and easily treatable disease takes 1.3 million under-five lives a year, a large proportion of those in India (over 1,000 daily on the subcontinent) (2). With counseling on hygiene practices, we can prevent diarrhea by stopping the root cause of microbial transmission. Additionally, the best treatment for diarrhea is the simple and cheap solution of “oral rehydration solution” or O.R.S.

photo

The Rehydration Unit is built on lessons learned from previous experiences with fighting diarrheal prevalence in Fakir Bagan. Back in 2010, analysis of the monthly growth monitoring and promotion weights showed a strong correlation between low weights and having had diarrhea in the two weeks before weighing. This connection spurred a desire to focus in on diarrhea, as both a cause and effect of malnutrition. After studying the highly successful model of the International Centre for Diarrhoeal Disease Research (icddr,b) in Bangladesh, Calcutta Kids opened up the Diarrheal Treatment Center (DTC) in March 2011.

This first foray into treating diarrhea was highly successful, but in creating the Rehydration Unit, we sought to learn from the weaknesses of the DTC initiative. Funded by a grant the World Bank, Calcutta Kids had rented a separate space with a separate staff roster dedicated to the DTC. For the Rehydration Unit, we’ve gone in a different direction. While retaining the essence of the DTC (O.R.S., Zinc, counseling), we wanted the Rehydration Unit to be an integrated part of the central initiative of Calcutta Kids: the Maternal and Young Child Health Initiative (MYCHI) in terms of funding and staff. Health workers, with whom the mothers of the community are familiar and have a rapport with, deliver the innovative BCC materials (from games to demonstrations) and conduct the follow-up visits in the home. Funding is no longer dependent on external grant cycles.

photo (1)

Each 90-minute treatment at the Rehydration Unit has been divided into prevention and treatment modules for counseling. Along with counseling, we have adapted practices from the W.H.O on how to best manage diarrhea with O.R.S. and Zinc while learning from our experience with the Diarrhea Treatment Center. This combination of counseling and the clinical treatment at the Unit (all administered by the community health worker) allows us to treat the short-term problem of diarrhea and dehydration in the most effective way possible while changing behaviors to prevent diarrhea from occurring in the future. The protocol and rehydration unit checklist has been designed to include all these facets and create a conducive environment for health worker-mother interaction.

We have deliberately called the new unit, attached to our daily health clinic, a “rehydration” unit rather than a “diarrheal treatment” unit. Calcutta Kids is seeking to change perspectives on what the ideal treatment should be for diarrhea. Rather than treating diarrhea with anti-diarrheals or anti-microbials (as is common in most of India), the treatment at the Rehydration Unit calls for replacing the lost fluids with O.R.S. to restore the body’s fluid balance. O.R.S. is nothing more than a carefully balanced salt, sugar, water solution that restores the natural transport systems of the intestines. Despite its simplicity, it remains the gold standard for treating diarrhea. It’s discovery, like many scientific advancements, was accidental but fortunate.

In the early 1970s with the Bangladesh War of Independence raging, refugee camps were overflowing and cholera was highly prevalent. The standard treatment was “intravenous fluids while starving the gut,” but the clinical staff ran out of IV therapy. In these desperate circumstances, one Calcutta doctor, Dilip Mahalanabis, decided to try an untested and new treatment: O.R.S. Miraculously, the mortality rates dropped to 3.6% instead of the normal 30% to 40% with IV fluids (3). Calcutta Kids has had the good fortunate to spend time with Dr. Mahalanabis on a number of occasions and he advised us with the DTC.

In India, only 31% of doctors prescribe O.R.S. for diarrhea (4), and often antibiotics are overprescribed. The first component of the behavior change communication modules aims to change these perceptions in the mothers of Fakir Bagan, and hopefully enable the mothers to use O.R.S. themselves at home in cases of diarrhea.

Additionally, the causes of diarrheal incidence stem from improper health and hygiene behaviors as well as from lackluster systemic factors (in water and sanitation). Changing simple behaviors, including hand washing, food handling, toilet usage and disposal of feces, and exposure to open sewers and animal feces, can reduce diarrheal incidence enormously. Hand washing alone can reduce diarrheal incidence by up to 53% (5).

The Rehydration Unit is an example of the innovative and deep thinking way in which Calcutta Kids functions. Calcutta Kids is bringing the most effective, scientifically verified solutions to a community that needs them. Efforts like this will make child morbidity and mortality from diarrhea a fact of the past.–Pranav Reddy

Persuasion Dissected

Persuasion Dissected

(1)Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, et al. (2008) Multi-country analysis of the effects of diarrhoea on childhood stunting. International journal of epidemiology 37: 816–830.

(2) Santosham M, Chandran A, Fitzwater S, Fischer-Walker C, Baqui AH, Black R (2010) Progress and barriers for the control of diarrhoeal disease. Lancet 376: 63–67.

(3) Ruxin, JN (1994). “Magic bullet: the history of oral rehydration therapy”. Medical History 38 (4): 363–97.

(4) Taneja DK, Lal P, Aggarwal CS, Bansal A, Gogia V. Diarrhea
management in some Jhuggi clusters of Delhi. Indian Pediatr 1996;
33: 117–19.

(5) Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM. Effect of handwashing on child health: A randomised controlled trial. Lancet 2005;366(9481):225-33.

Child Health Counseling Training February

Since the last Calcutta Kids off-site training in May 2011, our staff members have frequently asked, when will we go away again for training? For our staff, training is more than just an opportunity to learn new skills, it is also a special and exciting opportunity to leave the office and their homes to spend a few days away– a much needed break from the daily grind. We held a long awaited training on protocols and child health counseling last week at Monobitan, a training center south of Kolkata in Pailan run by our friends at CINI. The training was a welcome opportunity to take a step back from our day-to-day work and enjoy some fun learning activities.

The first day of training was held on-site in our new community center in Fakir Bagan—Ma o Shishu Shiksha Kendra (MoSSK). The first task was to come up with an entertaining nickname name for each staff member, using an adjective starting with the same letter as their name. The name would be used throughout the training, and it proved to be a great source of amusement. The names ranged from simple— ‘Sincere Sima’ and’ Jumping Jayanta’—to more complex –‘Na sunne ka pasand nahi Nasreen’ (Doesn’t like to hear no Nasreen) and ‘Shundor moner odhikari Sumana’ (Soul with a good heart Sumana).

The goal of the first day’s training was to clarify protocols for program activities held in MoSSK. The day was spent learning about new protocols for Growth Monitoring and Promotion (GMP), our MYCHI Clinic, Immunizations, Nutrition Corner, Community Meetings, and Child Development Corner, all which are now carried out in MoSSK. The team members role-played each of the activities to internalize the protocol and enjoyed playing different parts such as patient, doctor, mother, and counselor.

The next morning the CK team piled into several Tata Sumo trucks and sped through the streets of Kolkata, heading south to our training site in Pailan. After a quick breakfast, we dove into the training sessions on child health. We focused on two new child health topics: Family Planning and Hygiene & Sanitation. They were not unfamiliar topics to our health workers, but they were new in the sense that we were introducing standardized education and training materials for them. Each topic session consisted of a lecture, videos, and the introduction of an innovative counseling technique. After the Family Planning session, Sriya, our AIF Fellow, who has been working on behavior change communication (BCC) for maternal and child health, introduced a technique called Forum Theater  an interactive form of theater that is used to demonstrate problem situations and involves the audience as part of the activity and resolution to the problem.

Chandan and Susmita participating in Forum Theater

Chandan, Malti and Susmita participating in Forum Theater

After the Hygiene & Sanitation lecture, our program coordinator Sumana, who has taken a formal training course on puppetry for community health and awareness, organized a puppet show on the topic performed by the AICs and CHWs in order to demonstrate another creative technique that can be used for counseling and BCC.

PuppetShow

It was incredible to see how quickly our staff members and, in particular, our health workers, adopted the new techniques. Performing both forum theatre and puppet theatre for the very first time, they successfully incorporated essential messages and both identified and found resolution to key problems using these two creative and interactive mediums.

As the day came to an end, the staff took time to enjoy the last bit of sunlight to walk around the gardens and playgrounds of Monobitan, pushing each other on the swings and merry-go-round. In the evening, we did a ‘guess the baby’ game which included showing baby photos of staff members and having to guess who they were. The highlight activity was the eco-friendly newspaper fashion show, where we split into groups by topic—popular female leader, favorite political leader, famous TV advertisement, movie, book, or cartoon character, and Bollywood actor or actress. Each group dressed up one or more models using newspapers and then walked up the runway as a group, using song or dance. It was truly a hysterical experience and brought out the creative side of our team members. Arpita dressed up as the Chief Minister and sang Ekla Chole Re along with her group. Kalyan posed as Rahul Gandhi, and Chandan danced around as the Joker from Mera Nam Joker—much needed laughter therapy for all of us.

NewspaperFasionShow

The next day, the entire day of training was group work, focused on new strategies for BCC including the forum theatre and puppet theatre techniques from the previous day, along with counseling cards, interactive games, poster making, role-play, discussion groups, visual media, and demonstrations. Participants were divided into five groups and given child health topics–PNC and Care of Newborn, Immunizations, Care of Sick Child, Feeding Practices, and Child Growth and Development. All of these topics are familiar to the staff and our health workers already counsel beneficiaries on these topics. However the novel task was to identify key messages, challenges in changing those behaviors, and present solutions in a new counseling medium. Each group presented their topic and form of counseling technique to the rest of the participants, followed by discussion and feedback. All the techniques mentioned were effectively utilized—and at the end of the session, the whole team felt that they had really learned new skills in the BCC arena, and accomplished something very important. We will take this confidence building to our work in Fakir Bagan community, imparting essential health messages through effective delivery tools. The health workers commented how each of them had started at Calcutta Kids with virtually no knowledge of maternal and child health, and now they not only have internalized the information and the messages, but are able to teach the women they work with in new and exciting ways that will truly change the face of counseling and behavior change at Calcutta Kids.

GroupPresentation

As we left Monobitan that evening, I think that each of us felt a sense of triumph, that the training was a success and we came away from it with so much knowledge. We also felt a sense of peace, and sense of togetherness, as I think the training solidified relationships within the organization and really made us feel that we are working towards a common goal. Our Director Noah commented that the training was ‘a memorable few days which not only strengthened our team as a whole but also strengthened each individual working at CKT.’                          —Sumana Ghosh and Danya Sarkar

 

The Art and Science of Diagnosis

A professor from Ohio State e-mailed me the article with the deceivingly understated subject line of all-lower case “fyi.” The Hindu write-up’s headline, though, didn’t mask the shocking contents: “Appalling condition of primary healthcare services” it read. (1) Short and potent, it described the lurid details of a study carried out across the health sector in India, rural and urban, private and public. The details showed a fundamental lack of ability by medical professionals to diagnose even the most common conditions (asthma and dysentery, for example) or ask the most basic questions (whether there was “pain radiation” for an unstable angina). The result was a low rate of diagnosis, whether it was in rural Madhya Pradesh or Delhi.

Overall, healthcare providers provided the correct treatment only 30.4% of the time. (2) Even worse, 41.7% of the time the clinics provided unnecessary or even harmful treatments for “patients” that the research study trained (“from the local community”, the article notes). Many providers, even in public clinics, were unqualified. Medical guidelines and treatment protocols were followed at low rates; providers only asked 33.7% of the recommendations. In Madhya Pradesh, doctors spent 3.6 minutes with patients, while Delhi medical professionals spent a marginally better but still terrible 5.4 minutes. For reference, the Medical Council of India recommends doctors spend at least 10 minutes with each patient. (3)

The article highlighted tough facts that Calcutta Kids has been tackling for years. Through our experiences with the health clinic, we’ve worked to combat the norm of primary health in India: brief, non-comprehensive visits and a disregard for protocols and checklists. We’ve uploaded to the resources section of our website our child health World Health Organization’s IMCI and IMPAC-based Child Health and Pregnancy and Maternal Health protocols and checklists which our doctors are trained and demanded to use. Our two health clinic physicians, Drs. Pal and Sen, work with our management staff to ensure that the protocols we have provided them matches their process for diagnosing patients. See the above-mentioned resources below:

Child Health Protocol (0-2 months)
Child Health Checklist (0-2 months)
Child Health Protocol (2 months to 5 years)
Child Health Checklist (2 months to 5 years)

Pregnancy and Maternal Health Checklist and Protocol

It’s an important process that Calcutta Kids has to do to ensure our beneficiaries get not just quantity but truly quality care. It hasn’t been an easy process to bring in this cultural change into our clinic over the years, but it’s a necessary one. In addition, the creation of standardized protocols ensures a consistent level of care that our beneficiaries can expect, regardless of personnel changes. As Atul Gawande noted in his Harvard Medical School commencement, it’ll require an understanding of a team of healthcare providers- a “pit crew” that includes our health workers- not just the lone cowboy physician:

“The work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.” (4)

Many rightly criticize the low rates of spending on health per GDP in India, ranking 171st out of 175 countries according to a WHO study. (5) But the situation is even grimmer: it is not enough to just increase spending, build more primary health centers or even to write diagnostic protocols at a national level. The groundwork of implementation at a doctor to patient level must be accomplished. At our health clinic, we work on this ground level to make sure that provision of the highest level of primary healthcare is a reality for the mothers and children of Fakir Bagan.–Pranav Reddy

Citations:

  1. Appalling condition of primary healthcare services. The Hindu. R Prasad. December 6, 2012. Retrieved from http://www.thehindu.com/health/medicine-and-research/appalling-condition-of-primary-healthcare-services/article4167677.ece on Jan 1, 2013.
  2. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. J Das, A Holla, V Das, M Mohanan, D Tabak, B Chan. Health Affairs. December 2012. 31(12):2774-84
  3. MCI wants docs to spend at least 10 mins with each patient. The Times of India. K Sinha. September 1, 2011. Retrieved from http://articles.timesofindia.indiatimes.com/2011-09-01/india/29953546_1_opd-patients-doctors on Jan 1, 2013.
  4. Cowboys and Pit Crews. The New Yorker. Atul Gawande. May 26, 2011. Retrieved from http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html#ixzz2H02jhJMO on Jan 1, 2013.
  5. World Health Statistics 2011 Report. World Health Organization (WHO). 2011; 127-139. Retrieved from http://www.who.int/whosis/whostat/2011/en/index.html on Jan 1 2013.

The Story of Puja Yadav

I will never forget the image of Puja on that first day of YCHING (Young Child Nutrition Group) in April 2011: Her mother Rinku set her down on the ground, and she took off, a whirlwind of 11 month old energy, tottering on slightly bowed legs, eyes bright with promise, grinning ear to ear. She was a radiant child.

Puja in April 2011

Fast forward to January 2012: Puja’s family came back to Fakir Bagan after a 10 month stay in the village during which time Rinku delivered her fourth child, Prince. Rinku had conceived again when Puja was just 9 months old, and the family–which included Rinku, her husband, Puja’s older brother and sister, and Puja–decided to return to the village for the pregnancy and delivery and to be close to extended family at home. The next time we saw Puja in January, we were shocked to see her condition–gone was the sunny, energetic girl we knew a year back. The new Puja was sullen, lethargic, and irritable. There was a clear reason: after taking her measurements we found that Puja had dropped off her growth curve, plummeting from -2.2 in weight for age z-score (WAZ) in April 2011 to -3.6 WAZ in January 2012. She was severely underweight and obviously suffering from infection. We counseled her mother and urged her to bring Puja in for examination and treatment, but with the new baby, plus Puja and her older siblings, Rinku was overwhelmed and decided to return to the village before we could intervene.

The family reappeared in Fakir Bagan in June 2012 and we were dismayed to see that Puja, now at 27 months, had taken a turn for the worse.  She was now -4.8 WAZ, very severely underweight, and also severely wasted at -3.03 weight for height z-score (WHZ). She suffered from both chronic and acute malnutrition- she was very weak, had raspy, labored breathing, a swollen abdomen, and chronic fever. She urgently needed help. We were sure she would not survive if she continued on this downward spiral.

Puja in June 2012

The Calcutta Kids doctor examined Puja and we quickly put together a treatment plan for Puja. First, we referred and accompanied her to Hope Hospital in Kolkata where she could be seen by a specialist pediatrician. The pediatrician diagnosed her with severe protein energy malnutrition (PEM), severe anemia, and chronic infection, and suspected that she had TB. He ordered a battery of tests and we sent Puja to the local DOTS (Directly Observed Therapy) center for TB screening. Though her Mantoux test was negative, her chest x-ray showed severe infection in the lung.

In consultation with the Hope pediatrician, Puja is now taking a 3 month course of level I anti-tuberculosis drug for her lung infection and therapeutic micronutrient supplements. Rinku brings her to the Calcutta Kids clinic everyday for an energy and protein dense, nutritious meal. Our health workers visit her home regularly for follow up and counseling on care, hygiene, and nutrition with the family.

Puja and her mother Rinku, July 2012

Puja Yadav, like all our children at Calcutta Kids, was never just a ‘case’ to be managed. She was a child at risk, a child trying desperately to survive the odds around her–a life that would not only be lost, but discounted, if someone did not intervene. Our entire team rallied together with Puja’s family.  We had intense discussions, we shed a few tears, and we cheered when Puja started gaining weight, slowly but surely; started smiling again; and even laughing. We are very happy to report that Puja has started to blossom again, and is slowly starting to resemble the girl we met over a year ago. In two months, she gained 1.5 kg, and shot up from -4.8 WAZ to -3.5 WAZ. She has improved from severe wasting (-3.03 WHZ) to mild wasting (-1.38 WHZ), a remarkable turnaround. And all of this has happened with home-based care, which is much harder to adhere to and manage than institutionalized rehabilitation, an option that the family would not consider, because it would mean leaving the other children at home without a full-time caregiver.

Like Puja, the family has started to change as well. Initially, both father and mother did not want to take Puja to the DOTS center three days a week for medication. They feared Puja would be labeled as a TB patient and ostracized by their neighbors. Calcutta Kids counseled them and gave them confidence to explain to their neighbors why they sought treatment for Puja. The community around them has also seen the changes in Puja and supports the family’s actions. Furthermore, as Puja’s health has improved, her younger brother Prince has also made remarkable strides. He, too, had been severely underweight when they came back from the village in June 2012. In the past 2 months, Prince moved up to the moderate category, gaining 1.2 kg, going from -3.47 to -2.4 in z-score (WAZ). We believe that this is another testament to change that has occurred in the family and especially in Rinku, who now seems less burdened, more confident, and proud of her children. When she brings Puja to the clinic she is delighted when Puja calls our health workers ‘amar didi’ (my elder sisters) and when Puja holds her hands to us in ‘namashkar.’

Puja now–August 2012

Puja is a true fighter. She is still the vibrant spirit who caught our attention long ago. She and her family just needed some extra attention. We at Calcutta Kids feel privileged that we were able to provide that additional help. We are committed to making sure that Puja remains on this trajectory of growth and nutrition, a critical foundation for a healthy and productive future. –Danya Sarkar

Puja’s Weight for Age Z score.
(Ideal is a straight line at 0)

Puja’s Weight for Height Z score.
(Ideal is a straight line at 0)

Beating the Heat with Mangoes

It’s hot here in Kolkata—incredibly hot. Humidity levels are hovering around 95%, and the mid-day temperatures are reaching as high as 112 degrees Fahrenheit. With such weather, one would expect productivity to reduce, but with so much going at Calcutta Kids these days, productivity remains high and much is being accomplished. I’d like to use this blog post to catch you up on our news and give you snapshots of what is keeping us so busy.

• A new MCPC—Since 2005, we have used the same Mother and Child Protection Card (MCPC) to keep track of the growth of pregnant woman and children; remind families of best healthcare practices; and track their immunization status. Over the past several months we have revised and improved upon these MCPC cards. The changes include updating the growth chart to be consistent with that of the government of India and WHO; sections added for monitoring deworming, home visits, breastfeeding/complementary feeding; and additional space allocated for measles vaccine and for non-CK immunization information. Our Community Health Workers have collected the old MCPC cards from our beneficiaries and are tirelessly transferring information from the old cards to the new cards. 

• Medicine database overhaul—Evan Mullen, our summer intern through the Skolnik Internship Program arrived in Kolkata last week after completing his sophomore year at Yale University. Along with overhauling our medicine database to ensure the most efficient use of medicines, Evan is also working with our doctor, Dr. Mukherjee, on learning and then implementing the WHO/UNICEF-created Integrated Management of Neonatal and Childhood Illnesses (IMNCI ) protocol so that all of Calcutta Kids’ curative care is done following this established protocol.

• Music for our beneficiaries—as part of the launch of their second album, the well-known Bangalore-based band Swarathma will be performing a free concert for the beneficiaries of Calcutta Kids. (This is a real honor for Calcutta Kids and our beneficiaries—the night before, the band will be playing at the most prestigious music club in Kolkata, Tantra, at the Park Hotel.) Especially for the women and children of Fakir Bagan who rarely venture outside the slum, this concert will be a special treat. Our blog next week will be a review of this concert.

• A new HR manual—Having years of HR management experience at the Akanksha Foundation in Pune, the Child In Need Institute in Ranchi, and ITC in Kolkata, Evangeline Ambat has joined Calcutta Kids as a consultant to design a new Calcutta Kids human resources manual. The Calcutta Kids staff has asked for a comprehensive HR manual and we are confident that Mrs. Ambat will be able to deliver this much-needed document.

World Bank Development Marketplace Nutrition Award wrap-up—MYCHI Project Coordinator Sumana Ghosh and CK Director Noah Levinson, are planning their presentation to share in Kathmandu about CK’s experience with the World Bank funded Diarrhea Treatment Center . The conference takes place on June 11th and 12th and is titled “Sharing Lessons from Community Experiences: Improving Infant and Young Child Nutrition”.

• AIF Fellowship transition—this is Margy Elliott’s last week at Calcutta Kids concluding her ten month William J. Clinton Fellowship through the American India Foundation.  Along with building the new Calcutta Kids website, Margy has created a field-level manual for illness assessment and treatment guidance for use by our community health workers, she has been an essential part of designing and implementing our new community mobilization program, she has helped to raise funds for Calcutta Kids, and she is now wrapping up an intensive SWOT (strengths, weaknesses, opportunities, threats) analysis among key CK stakeholders. Margy has become a member of the Calcutta Kids family and we will sorely miss her. That being said, however, thanks to Margy’s marvelous experience at CK, AIF’s Clinton Fellowship Program is providing us with two fellows for the 2012-2013 year. We are excited about welcoming Pranav Reddy, and Sriya Srikrishnan who will begin working with us in September.

So while we are drenched in sweat and continuously drinking plain and coconut water to keep ourselves hydrated, there is one saving grace to this weather— mangoes. For those of you who have experienced the intoxicating flavors of the wide variety of mangoes in India available at this time of year, you’ll understand that the mangoes are almost worth our suffering from this heat. For those of you who have not…you may enjoy reading this New York Times article which nicely explains how fantastic these mangoes really are. -Noah Levinson

Immunizations – More Than Just a Shot

The immunization program has been a service of Calcutta Kids for many years, but during the last year, we have worked very hard to make it as effective and efficient as our GMP program. There are two primary ways that we have accomplished this; the first is a short multimedia education and counseling session and the second is a system in our database that tracks the immunizations for each child and correctly identifies those who are eligible for that week’s clinic.

Rather than simply telling mothers and caretakers that these immunizations are necessary, we are working to inform our beneficiaries about why these immunizations are important. The short education and counseling session is designed to convey information on both the disease (or diseases) that the immunization is preventing, and on possible side effects. We have already seen mothers taking a larger interest in the immunization program and asking the CHWs about the next session. And for those not taking the initiative, we have an accurate list of all children who should come to the clinic and take the time to remind each household on that list. Take a look at the immunization counseling materials here.

The immunization section of the database has been greatly improved in the past year, and now takes into account the immunizations that have been received and the dates of each immunization received. This is important because many children have missed doses and are therefore off the ideal schedule. For example, a child may have received the first dose of DPT, OPV and Hep-B, but then did not receive the second dose after four weeks, but instead returned after eight weeks. According to the age, the child should be receiving the third dose but in fact, he or she should be receiving the second dose. The system also makes sure that enough time has passed between doses. These two improvements are helping us toward our goal of full immunization for each child that participates in our program. -Dora Levinson

Saving a Severely Malnourished Child

Ajay was born on August 20, 2011 in a village outside of Kolkata. Sadly, his mother died shortly after childbirth, and he was sent to be raised by an aunt, also in the village, who had two other children. Over time, Ajay grew malnourished and his aunt was unable to provide proper care for him. In late 2011, he was sent to live with another aunt named Pramila in Fakir Bagan, where we work. Pramila has been married for many years, but has never had any children of her own.

Ajay and Pramila in late January, 2012

Pramila learned about Calcutta Kids and on Friday, January 20, she brought Ajay in for his first immunizations at five months old. Our triage nurse was quickly alarmed; his distended stomach, loosely hanging skin, bulging eyes, skinny limbs, and lethargy made her nervous about the inoculation. Weighing in at 3.79kg (~8.4lbs), he had a weight-for-age Z-score (WAZ) of -5.392, which was off the growth charts in the severely malnourished category. Bringing him to the attention of our health workers and doctor, Ajay received a thorough examination and a counseling and nutrition plan began. Ajay’s dirty bottle and diluted cow’s milk were replaced with clean bottles and newborn formula. Thankfully, he was hungry and eager to recover.

Starting the following Monday, Pramila brought Ajay to the Swastha Kendra (health center) daily for supervised feeding of Ajay. CK mothers are always encouraged to exclusively breastfeed, but in this case, without a lactating mother and with the severity of Ajay’s malnutrition, formula became the only viable option. Thanks to generous donors, CK supplies Ajay with all of his formula, which is expensive but critical to his growth. Almost immediately, we also started complementing his formula feeding with kicheri (lentils, rice and vegetables), which he ate well. Our community health workers conducted regular home visits to make sure that feedings were successful in the home. By February 1, Ajay weighed 4.5kg (~9.9lbs), and had a WAZ of -4.49. Making great progress, he was looking healthier and had more energy.

Ajay in late February, 2012

Pramila was also taken in by our mother’s support group. They were eager to help her, and invited her to attend their meetings. At one meeting, they taught Pramila various ways to make household ingredients into baby food. As a first-time mother of a very fragile child, the women in the support group also took the initiative to visit her and make sure she had what she needed. On March 1 he weighed 5.7kg (~12.6lbs) and had a WAZ of -3.633. His cheeks and limbs were starting to fill out, he was able to roll over on his own, and his smile could light up a room.

Ajay and Pramila in late March, 2012

Ajay and Pramila have continued coming to Swastha Kendra 2-3 days per week for counseling and food. On March 20, two months after Ajay’s first visit to Calcutta Kids, he weighed 5.97kg (~13.2 lbs) with a WAZ of -2.95, and was officially out of the “severely malnourished” category. Throughout the whole process, Pramila has worked very hard, heeding the counsel of Calcutta Kids, and has expressed her gratitude for our programs.

Ajay and Pramila in late March, 2012

Sitting in Swastha Kendra, I am fortunate to be able to see Ajay and Pramila regularly, observing the feeding, assessing his progress, and enjoying their company. The transformation in this sweet child over these 2+ months has been remarkable to witness. Thanks to the great work of Calcutta Kids, he continues to grow well, and is reaching both physical and developmental milestones. – Margy Elliott, Fellow, American India Foundation

The Next Generation of Development Workers

While not a primary objective of Calcutta Kids, one of the roles we have found ourselves embracing is that of a mentoring organization for the next generation of western development workers. The organization is, in fact, flooded with applications from students seeking internships with Calcutta Kids (from which, unfortunately, we’re able to accept only a limited number.) Maybe this burst of interest is because Calcutta Kids was itself started by a young Westerner with whom young people can identify, perhaps it’s because Calcutta Kids embodies for some, what Nicholas Kristof refers to as the D.I.Y. (Do It Yourself) Foreign-Aid Revolution , or maybe it’s simply because of our clear objectives and proven track record. Whatever the reasons, we have, in taking on interns, been entrusted with an important responsibility, one we take very seriously.

Since Calcutta Kids Trust commenced its work in 2005, we have had the opportunity to work with over 20 undergraduate, graduate, and post graduate student interns from Europe and the United States, most of them having a public health interest or background. These interns usually spend between 2 and 10 months working on a specific project with clear objectives and an achievable if strict timeline. Projects range from illness-specific training and treatment protocol development to project evaluation to website development. The internships to date have been overwhelmingly positive for both the interns and for Calcutta Kids.

Apart from the value of their projects – which have invariably been valuable to our on-the-ground operations, these students have often opened their networks to Calcutta Kids for fundraising purposes, an unexpected but much appreciated by-product of the internship. When queried about it, they indicate that having seen the inner workings of the organization at close quarters – having participated in such a range of activities, been privy to managerial deliberations and financial records and having seen first hand the effects CK are having on these disadvantaged families, they believe sincerely that this is an organization they’d now like to support financially.

So along with providing an opportunity for this next generation of development workers to put into practice the theories and concepts they’ve learned in school, the Calcutta Kids’ internship program allows young persons to see and experience the workings of an organization guided both by values and by evidence. We hope that through our role in mentoring this next generation we can not only encourage replication of some of CK’s successful models, but, perhaps more importantly, inspire these young people to take the lessons and values gleaned from CK into their future work. – Noah Levinson

Our New Community Center is Open!

 

On January 11, 2012, Calcutta Kids opened a new community center – called Maa o Shishu Siksha Kendra (Mother and Child Learning Center) in the community of Fakir Bagan.Although the other Calcutta Kids facilities are extremely close to the slum neighborhood, this is the first center located directly within the community. Calcutta Kids plans to utilize the space for the monthly Growth Monitoring and Promotion program, for community meetings, and for mothers’ support groups, among other things.

Mothers, children, and community leaders supported Calcutta Kids at the ribbon cutting ceremony. At the event, numerous mothers spoke about their appreciation for and success because of Calcutta Kids’ services. Noah Levinson, Calcutta Kids’ Director, said that this was the beginning of a new era for Calcutta Kids, an era where the community would play an important role in defining and directing our programs.

Momentum in Calcutta

Dear Friends of Calcutta Kids,

I’m hardly an unbiased observer, but one can’t help but be impressed with the extraordinary sense of momentum, the sheer energy that’s now being generated by the program. One feels this not only among the community health workers who are simply not allowing any pregnant woman or young child to fall through the cracks, not only among the data analysis team members systematically tracking progress and effectiveness of each of the program components, but also among the beneficiaries themselves: the young mothers exhibiting such pride when they observe their children’s weight gain, the new parents beaming when they that all their efforts have paid off and their newborn is born healthy and with adequate birthweight.

That’s pretty qualitative. There has been a quantum leap in the systematic gathering of monitoring data during the past year – and there will be lots to share in the months ahead. Here’s an example which I find pretty dramatic: The data analysis team has been comparing the effects of the Calcutta Kids program with those reported in the National Family Health Survey for urban slums more generally in this state. While one third of the infants in the slums of West Bengal are born low birthweight (less than 2.5 kg or 5.5 pounds), the Calcutta Kids program has been able to cut this figure nearly in half – to 17%. The program also has been able to reduce severe malnutrition in young children by 25% below the state average, a significant improvement in an area still ridden by such environmental hardship. You should have seen the proud smiles on the faces of the community health workers when those findings were announced!

Another example of this “culture of curiosity” has been an analysis of families with kids who are severely malnourished. What are the characteristics of these households? What do these families have in common, and how are they unique? This information will be invaluable as Calcutta Kids seeks to eliminate severe malnutrition (which places the child at such risk and has irreversible consequences) from these slums. There is even a plan to examine the pathogens present in these children – work being initiated with the National Institute of Cholera and Enteric Diseases.

And another observation: It’s been clear to the Calcutta Kids for some time that the problems of malnutrition and of low birthweight in India –much worse than in Africa despite India’s rapid economic growth – are symptoms of the lower status of women. Calcutta Kids has been relentless in addressing this problem, working both to empower women in these slums, and to celebrate the female child while actively involvinghusbands and mothers-in-law in the process. And one can begin to feel the change. Women work together more closely. They speak out more confidently. And it seems to me that they’re holding their heads a little higher.

You’ll be pleased to know that as of this month, 850 families in the slum are covered by Calcutta Kids’ low cost health insurance (costing less than $2 per person per year). Calcutta Kids is looking for new and creative ways to increase both enrollment and renewals so that the tragic pattern – so frequent in these slums – of families forced into severe debt when serious illness strikes, can become a thing of the past. The insurance program received lots of timely advice from Susan Richardson, former vice president of United States Liability Insurance Group, a Berkshire Hathaway company who spent 6 weeks with the insurance team.

And, finally, the very impressive Calcutta Kids Diarrhea Treatment Center (DTC) is ready to begin operations. In addition to the Center’s life-saving efforts, the documentation of effects through pre-post surveys will offer considerable insight into the cost-effectiveness of this approach for India’s slums.(You should see the new DTC doctor. She’s a house on fire!)

And this work is not going unnoticed. During my time in Kolkata we had visits both from development agencies and from public health experts like Jon Rohde, former director of UNICEF in India and Dilip Mahalanobis, credited with the discovery of Oral Rehydration Solution. All have been curious, as I have been, to fully understand what’s behind the remarkable success being achieved here.

At the beginning of February, the primary public health institution in the state awarded Noah their Founders’ Day Award in recognition of these accomplishments. Noah, in typically humble fashion, passed on the honors to the rest of his team.

Sincerely,

Jim Levinson, Vice President

(From February 2, 2011)