The Change Agenda : Health

One of the sectors that I believe that needs to rework some of its strategies for implementation is the health sector. Most of the national policies for health, specially under the NRHM, though have some specific clauses for mountainous and tribal regions, there are certainly two issues that are not adequately covered in terms of policy or practice. 

The first issue is site selection for health facilities. Most health facilities (health sub-centers and Primary Health Centers) stand on lands donated by a local community member. We all know that except in few cases, often there is a need for cajoling someone into offering a plot of required land at no cost or at exceptionally low price because that is what the community is willing to pay collectively for it. So, what do you get for free or minimum cost? The minimum! Often the place is in a very vulnerable location either near a river, or on a slope or in flood prone location, as it happens in deltaic plains. Placing critical life line structures in vulnerable locations is not a right approach. This needs correction. The governments may have have to buy the land or at least a proper land area vulnerability assessment must be done before a plot of land is purchased.

The second issue is the case of vaccine packaging. Those in health sector know that most vials with vaccines for children come in doses of 10. Even in the plains where the population is much higher, it is difficult at times for the health Staff to open a vial because there aren't enough children to whom she can administer the vaccine. In the hills of Uttarakhand and in similar terrains in the country, where the population is still thinner and spread in far off places, this is much more difficult. So, either citing the policy the vaccine is not administered as the health staff cannot open the vial, or, the vaccination gets delayed, and the chances of a child not getting vaccinated increases. There is a serious need for the Ministry of Health and Family Welfare to review the policy on medicine procurement - specifically relating to packaging of vaccine vials. The manufacturers must be clearly instructed to prepare vials of 3 dozes for the hills and 5 dozes for the plains. If there are problems in production of multiple types of bottling, the vaccines can be packed in dozes of 5 per vial across the country. This would reduce wastage, improve vaccination and ensure greater results. Once the size of the vials is changed, the rules can be altered to ensure that even if there is one child, the vial can be opened so that no child is missed!

Prices with pharma companies must be renegotiated as these may try to sell hard the larger vials because they get paid based on the number of doses a vial holds.

Kedarnath : Satellite images showing pre-disaster  & post-disaster situation; In the post-disaster image (right) you can also notice the birth of a new stream!

Susceptibility and Consequential Vulnerability

As I continue to work on the Social Sector Plan for the most affected villages in five districts  of Uttarakhand, along with lots of inputs and preparatory works from my colleagues in the districts and in the State, I began to wonder about one thing. What are we really focusing on? Or rather, what are all the humanitarian agencies focusing on in their emergency response in Uttarakhand. As I kept pondering through these questions, in one of the daily mails that I share with my colleague (and mentor ) Sarbjit Singh Sahota of UNICEF, wrote " Response to Event Vulnerability will happen, but what about our response to Consequential Vulnerability?"

The people who were most vulnerable and highly exposed at the time of hazard striking them are dead and gone. Families have have lost their loved ones, bread winner, cattle, shops, valuables, almost everything ! The humanitarian agencies continue to respond with food baskets, clothes, temporary shelter, medical camps etc. There is an attempt to strengthen the emergency response system, the critical infrastructure and life line services which have been highly impacted in these districts. So, we are taking care of the "event vulnerability", i.e. people and resources who were vulnerable and have been affected by disaster are taken care of temporarily.

But what about Consequential Vulnerability -- vulnerability that is born of a disaster? People who were better off or in lower middle class, now have become poor. People who had land have now become landless and homeless as their houses and land were carried away. People who had a bread winner at home have become widows, father or motherless, orphans. People who could cultivate some grains have become paupers. Those who earned from shops and cattle have now come to seek asylum. 

The way we treat consequential vulnerabilities today will have an impact on event vulnerabilities and susceptibility of these people to disasters tomorrow.

Time the Compensation

One of the questions I have begun to ask in this assignment in Uttarakhand state is: Is the timing of giving compensation to families who have lost their houses "the right time"? Let us examine the facts. 

Usually after a disaster, immediately there is a hue and cry for compensating the loss. The governments, in order to get a political mileage and to silence the voices, immediately announce a compensation package, and at times it is even revised to increase the earlier package. In the case of Uttarakhand, each family that had lost its house got 200,000 rupees. Indeed, although the disaster had taken place on 16 - 17 June, during my visit to Pithoragarh district closer to the Nepal-Tibetan border with India as early as in the first week of July, I found that the families had been compensated. I was pleasantly surprised at that time the compensation has reached the community and people are happy that they received the money without any delay.

But this is the rainy season. People do not have much work. Most of the affected families are living on the generosity of the government which comes through free or subsidized food and some benefits given by the non-profit organizations. Today, that is about two months from the disaster, how much of that 200,000 is left with the families to reconstruct their houses? In any case with the rains continuing, the house reconstruction cannot start before October. So, how much will be left on the first day when the deprived family needs money? People eat, purchase clothes, pay for medicines, they travel and buy some utensils etc. with the same money.

This takes me to the first question: Is the timing of giving compensation to families who have lost their houses "the right time"? Or, should the "housing compensation be better timed?". One option I would propose is the following (an idea I shared with a few and later I wrote to Eilia J. in Care India yesterday, to share my opinion. 

Hon'ble Chief Minister of Uttarakhand gives compensation 

I would propose that the government gives the money in 3 or 4 installments; and all installments should be paid as advances (unlike in Indira Awaj Yojana where money is retroactively paid). This might have some force on the families too to take responsibility for the money and the house, while at the same time help in standardizing, completing the housing, and improve the the Cash Transfer mechanism as well.

If given in one time advance, it looks like the government has given the compensation, and it has technically washed its hands off! A longer term engagement by splitting the money will also give space for more dialogue on land rights, land usage issues, environmental concerns, risk prevention and management etc. 

May be it is time to rethink some of our compensation policies.

Working with Body and Mind

On 21 July, on arrival I checked in into a hotel on Rajpur road with a bit of bargain, after they agreed to give breakfast and dinner as complimentary for Rs. 1,500 per day. My room was in a corner, with very little light coming into the room. The pressure of work was catching up on me. On 22 July, Monday we had the initial orientation with Sarbjit ji leading it. On 24th we were busy in the morning at a Coordination Meeting called by  Sphere India and State Inter Agency Group at Hotel Aketa. Mr. G.Padmanabhan joined us in the afternoon, as we were told that GP (as we fondly call him) would be staying with us as an expert guide on the part of UN. So, that is going to be my biggest asset as I can count on his wisdom and experience.

We were given 10 days time to complete the first part of our task: clusterization of affected villages and prepare a Social Sector Plan for five districts. By the second day I could feel the heat of work, as I found that there is vast difference in the quality of people I had at hand. It was getting tough each day: there were several meetings lined up each day at the state level with various departments, break the grey cells to plan how this Social Sector Plan would look like, and coordinate the six district coordinators who had come with various experience, culture, educational level etc. And, as myself was unsettled, I was really wondering if I fit into the shoes.

In the second week, on Saturday and Sunday (27th & 28th) I took some time off and went around searching for a cheaper and better place to stay. It was certainly a frantic search, as I saw whatever little money I had was getting eroded day after day. At last I found a place "Butola's"--a new guest house just two months old. The rooms were clean and tidy, the room was bright, and even I had a bit of sunlight into my room at different times of the day. Though the place was about 5 km from the Secretariat (the headquarters of the Uttarakhand State Administration) from where I am working currently, it was well connected by road. And it was just about 2 km from my colleagues P.D.Mathur's home. So, at last I shifted there at Rs. 3,500 per month, and with additional 2,500 for breakfast and dinner. Since I found that the food is not worth it, after two weeks, I opted out of the dinner package and kept the breakfast only.

Once I got settled, I was now able to focus better on work. By 30th July I cracked the idea of how to make the Social Sector Plan, and started working on it. But, because the data was not coming from the districts, it kept dragging eternally, and by 15 Aug, we could complete just 3 of such plans. Two more are still pending.

But in the meanwhile, I have been able to get into lot of networking with several departments of the government: Women & Child Development Department, Education, Health and Disaster Management - to be specific. I also found some not so frequented sections to come around and help me. I took assistance of the GIS section in the Disaster Mitigation and Management Center and the NIC cell within the Secretariat to help me with several information or to validate certain information. 

I also grew in good friendship with GP, Sarbjit ji, Shachi, Rahul, P.D. Mathur, Shailesh, Divya and Aashima. Aashima left the team due to personal reasons after a three week stint here. I also got some new friends in the government: Mr. Sudhakar, Mr. Badauni and Ms. Suman. Things are shaping up for better. I have a hope of completing the assignment on a high, though I have to work long hours that take a toil on my body and at times on mind.

Note: Indeed in the second week, I was so stressed that I took a stress test and other tests relating to heart just to check if I am fine. Or, else I should quit this place. But, luckily, my system was able to take it and move on.

The Journeys

On 7th we traveled from Munsiyari to Pithoragarh. On way we were informed that due to bad weather helicopters won't be flying, and so we will have to come by road. Noting that the roads are in extremely bad conditions and we were really up in the mountains, we knew that we would be having some real long travel. Bharati, one of our colleagues wasn't feeling well. We gave an avomin so that she would not vomit on the way, and we reached Pithoragarh at about 1.00 pm. We had lunch and we traveled again, crossed Almorah, and traveled further West, and at last stayed in a little town on the way as it was already 9.30 pm, and it wouldn't be safe for us after that. Our driver, Mr. Neeraj had been driving since morning 7.00 am from Munsiyari. On 8th morning at 7.00 am, as it continued to rain we left for Dehradun and reached at 4.30 pm. This was really a very long drive. 

On 9th & 10th, we continued with preparations of our reports, and on 11th I traveled back to Delhi, and then to Kolkata. My friend Tanaji was kind enough to allow me to use a car to reach home at night itself. I had three students from Seattle with whom I had planned to have dinner. So, on arrival in Kolkata I traveled to Tung Fung and had a good dinner. Then proceeded by car to Bolpur.

On the Risky Terrain - Women, Vulnerability and Disaster

06 July 2013: It has been raining since 5th noon, and it was just getting worse. I along with Rahul and Bharti went to meet few officers in the Block Administrative Office, took some data, and then proceeded towards Madkot, from where we should be going to a village called Devibagar, which was on the other side of the river. The roads were getting more damaged due to the rains, and in several places it was slippery. I was saying a prayer in my heart, as at several points I could feel that the wheels were just dragging on the wet slippery surface. When we were about four kilometers from Madkot, we saw that the road has been blocked as new debris had come down the mountain and few men were working at it. Seeing that on both sides vehicles had stopped and that the road looked very unsafe.... (we could see deep cracks appearing on the road which would after all fall into the ravine that had water cutting from below the road at over 70 feet down! It was frightening even to look at the water.

Seeing the situation we asked Bharti to return to Munsiyari, and we two men along with the IDBP soldier, began to walk towards Madkot. I kept looking in front of me and on road making sure that I am neither too close to the edge of the road nor closer to the mountain, and avoid water that had turned muddy by then. Suddenly, the soldier shouted at me, "Sir, Stop! STOP !" I stopped and turned back to him and asked, "What happened?" He said "You see the debris is coming down the hill from up? You need to look up as well!" We waited for the debris to fall, and then we jumped past that and we walked towards Madkot, wondering - "What a risky life is this! In flood prone areas, I should be careful of whirlwinds. But here what I have is - I need to look ahead of me, below me and above me, even to take a step forward!" Another prayer in heart : "God, please take me back home safely!"

After we crossed through Madkot, another three kilometers of walk to Devibagar. We stopped a gentleman in his late thirties or early forties who was walking with a young girl (approx 17 - 19 years), and asked him about how the disaster has impacted his life. He said that his house is safe, but food prices and transportation are the concern, and he did not want to talk to us because, pointing to the girl he said, he was taking his wife to the doctor! Alert, certainly in this place child marriage is rampant.

When we reached Devibagar and got into the Tourist guest house closer to the hot spring there, the eight families living there came forward, and we had very good discussion. The families took us around the affected area, spoke about how their houses were washed away by the river and how much of compensation they got etc. The children mentioned that they were studying in the Madkot school which has been washed away, and they are not sure where they would go to for schooling.  The families sounded desperate as they did not have any work and were living on the ration (relief food items and the money they got. The men and women kept mentioning that they are not getting work, even the road work. Their desperateness was on their eyes, looks and body language. I also noticed that this was the only village where I saw at least 6 young girls in their teens, which was not the case in the villages where we have visited so far, where I hardly saw a young girl. So, the question began to come to my mind:

Are these girls vulnerable to be trafficked? Why aren't many girls in other villages, including Madkot which is more thickly populated? Have the girls of those villages been already married off or trafficked? So, in that case, is Devibagar better than others - in protecting their girls?

Walk Down the Death Hill

05 July 2013: As we left our hotel a little later than usual : at 8.30 am, and we went to the local administrative office. One or two officials were beginning to come at about 9.00 am. We took some information from them about a relief camp in Dhapa and in Jimighat which functions as a transit relief camp. We decided to go to these places as they were next to each other: Dhapa camp along the road side, after which there is no road connection (as it has been cut off) and Jimighat down below the hill. We crossed Dhapa after about 50 minutes of drive on a bad damaged road, and went further for about a kilometer, beyond which we could not proceed. We decided to walk. Initially, the road wasn’t bad. As we began to walk down, we met two village travelers walking up. I stopped them and ask where they were heading to, where are they coming from and how long is the distance. One of them stopped to answer: We have been walking well beyond Martoli (closer to Indo-China border) for the last five days, and we shall reach Munsiyari today. There is no food in the hills, and so we have been walking, going past one transit camp after another so that we can get some work, live in a relative’s home, and have some food. They said that their families are in the ITBP camps and may be shifted by the army once the weather gets better. I told these men to wait for us at Dhapa camp so that we can give them a lift to Munsiyari when we return.

We then walked down towards Jimighat. It was a steep, almost 80 deg slope down hill. We were holding on to few roots and rocks in several places as the path was wet and slippery. It was like learning to walk like a little kid in all fours! The walk down the hill alone took full 40 minutes. It was a very tall mountain indeed! When we reached there we saw a kind of a little tent which the men there (who were going around smoking and looked drunk) said, “This is the relief camp!” When we introduced ourselves they brought a banner and hanged on it, and they were happy to get photographed. I walked and saw that it is just a single room structure with lots of holes, filthy, and dark. They were cooking food for lunch. I realized soon that these men were smoking hash, and were blowing it upon your nose! We also found a large notice on one side of it : “Hotel School mein hai” (which means, “The hotel has been shifted to the school !” So, where is the school? The school does not function for want of students. Due to repeated disasters and social issues most children are staying in Munsiyari town for studies. (This is an information that we could empirically verify, although people said that it is true that many families in upper hills keep their children in smaller towns.) There was a little bridge that connects the Milam sector with the main area next to this camp. People coming from the Milam sector can sit here, eat, relax and then walk ahead.  The bridge was in a very dilapidated condition and can break any moment. We visited few families in the neighborhood, spoke to them. I hardly saw women, and just a few children, in comparison to the number of men. I kept wondering where have they all gone? This place is a clear threat to children and women. (I heard on next day in Munsiyari that in the Jimighat camp, on 5^th evening, after we had left, a woman was molested.)

The walk up was still more tiresome. We had to stop several times as our heartbeat went up and perspiring too much. On our way up, picked those two travelers at Dhapa camp, and traveled back to Munsiyari. 

Madness at Madkot

04 July: Both the teams left at 6.15 am after a cup of black tea that the hotel thoughtfully provided,  and we separated after picking up an ITBP soldier each from the camp. I had Mr. Neeraj as our driver and Mr. Suresh, an ITBP soldier as our companion, along with Rahul and Bharati, my team mates. As the car climbed through the hills, Bharati took ill, and we stopped quite a few times, and at Thal for breakfast. When we reached Munsiyari at 12.30, our stay had been booked at KMVN guest house, a government run building. The lady at the front desk told us that the cost of the rooms would be 1250 per night. I was surprised that it is pretty costly with the rooms not so well maintained, with no AC etc. However, we thought of continuing to stay there. We visited the Munsiyari block office and had a brief by the Addl. District Magistrate Dr. Raghav Langer who was stationed there to coordinate the relief operations. He gave us a lot of information verbally asked one of the block officers to give further information to us in printed formats. As it was taking time, we thought of collecting the information on the next day, have lunch now (it was 3.00 pm), so that we can visit a village on the same day.

We asked Bharati to stay put at the hotel since she wasn’t feeling well, and we three men (me, Rahul and Suresh) proceeded to Madkot. Our journey to Madkot took over an hour, although the distance was hardly 16 kms. The road had been damaged at several locations, but it had been “mended”. When we crossed the river Gori just ahead of Madkot, we saw the crumbling village. Its school and several buildings had been damaged or gone in the water about 90 – 100 feet down the valley. We had discussions with families, shopkeepers, the village leader and finally we visited also the relief camp where 12 families whose houses had been fully damaged were living.

Madkot village is an entry point to several other villages, and so it had lots of shops and the houses were well built. My first impression was that the people of the village cannot be too poor here. Purely looking at the houses, there were about 30% of families who can be classified as poor, as other families lived on shops or jobs, and they seemed to be better off. We were even surprised that there were two hotels in the village! One of them was just on the river bed, and might be threatened soon if the river doesn’t change its course, and the other was a lot more interior and in a secure location.

The relief camp had been set up on an abandoned building by a failed / attempted hydro power station in a nearby location. When we visited the camp, we saw the place to be clean. After a brief with the staff at the camp, we went to visit the families in the camp.  (I am not discussing programmatic issues in this blog, because this is a personal one. And so such have been presented in official reports. Only human stories and personal experience are mentioned here.)

We saw a man on wheel chair, two other men, few children and a old lady, and we started talking to them. Other family members had gone into the village as they go about their normal work and they return whenever they think off to come to stay at the camp. They had come with all their properties as they saw the river beginning to eat up under their houses. We saw dish antennas, parked cars, heaters and even power generators! As I said earlier, many of these families were not poor. But nature had punished them, and have been left homeless and landless now. The three buildings in the camp had two floors each, and in each floor two families were staying! So, well set!

Where politics steps in: We were told that the local Member of the Legislative Assembly has told these families not to quit the camp as this place is better secured, unless and until the government gives them a better house! Arrogance of leadership.

First Impressions of the Disaster

03 July 2013 : I knew even before I left Dehradun for Pithoragarh that this district is not the worst affected. However, I also knew that I had not been sent here on a paid tour. The UN and government must have had a specific reason to put me on this visit to Pithoragarh. At the airport which had just a small little concrete roof of about 10ft x 10 ft passage way that had been converted into the control room with the district Collector Mr. Neeraj Kherwal IAS sitting and the 2^nd Commandant of ITBP (Mr. Martolia, because he is from a village called Martoli) in Pithoragarh guiding the ITBP jawans and camps across the hills, and both of them giving briefs to the IAF helicopter captains….and several satellite phones and wireless systems set up to ensure flow of communication, and couple of tents and over 20 civilian and para-military vehicles lying on the side…. It all gave you an impression of you have landed in the midst of an English action thriller.

The district collector explaining about the disaster using map.

The Collector (also known as the District Magistrate) was very welcoming, honest about the disaster, explained the current situation through a map of the hills drawn by the ITBP that had been placed on a small display board. We could question him about the government’s response. Then we went to meet the District Disaster Management Officer Mr. B.S. Rana at his office, and thereafter to the ITBP camp for further discussion on the logistics. Mr. Martolia  took us into a large hall that is used for educating the young soldiers. The hall had a three dimensional replica of the region mentioning where the Indian villages are, borders are, various security camps are and where various passes and passage routes are. This was extremely important for us to understand which route we must be taking, and which we must avoid. This discussion was educative as well, as we decided to make a strategic change: Our team will be divided into two: two men will go to Dharchula and three of us will go Musiyari, and these two towns will be used as our bases to visit other damaged villages. As a guide and security, Mr. Martolia also offered to provide us with a soldier each so that each team is safe and comfortable in the unknown region.  (The maps we saw are security sensitive and so we were asked to delete them from cameras.)

We were tired as it was already 8.15 pm, and I had to update several persons about the present plans, logistics etc, We checked in at Punetha Inn after a little bargain on the rates. The manager of the hotel was accommodating, and we went to bed by 11.00 pm after a vegetarian meal.

Alert: Corruption in Airport

On 21 July, Sunday, I traveled from Kolkata to Delhi by Air India AI 763. I was to fly by the 11.10 am Jet Airlines flight to Dehradun from IGI Airport Terminal 3. As I went to check-in they saw that my suitcase weighed 19 kg, i.e. 4 kg more than permitted. The gentleman at the counter told me, you may shift 4 kg to your handbag as he gave me the Boarding Pass saying that he would issue me the luggage tag when I resubmit it. I rearranged a few things and I knew that I have not done much as there was not much space in the handbag too. A loader (the person who loads luggages) came to me and said he would get it weighed. When he saw that it was weighing 17 kg, he said, "Sir, you will have to pay Rs. 500 for the excess baggage. But I can get it done, you just give me some money!" I got a shock! Waaw....when did this kind of corruption get in? I planned to take the risk. I said, "Okay". He took the Boarding Pass from me.

He went to one of the counters, spoke to the guy on the check-in counter, and then got the luggage tag on my Boarding Pass, and got my luggage moving. As he was busy at the counter, I pulled out my Samsung SII Galaxy, switched on the audio recorder to capture whatever discussion may take place between me and him. He returned to give me the Boarding Pass and said, "See, it would have cost you 500. You give me 400 !" He stretched out his hand in front of so many passengers. I walked ahead, and he followed me. As soon as we were away from the lines, I pulled out two hundred rupee notes and two 50 rupee notes from my wallet and told him that I have only this much - Rs. 300. I also noted quickly in my mind the last four digits of one of the 100 rupee notes. He moved away quickly.

I too took a stroll around so that he does not begin to watch me, and then I asked one of the Jet Air attendants walking by for the Supervisor. He showed me towards the check-in counters. I knew that that is not the correct position for me. I walked up to another information desk and I told the gentleman there that I had to bribe someone and I want to make a complaint. He directed me to the GMR Information Desk at the Departure Hall. I narrated the event to the gentleman there. He was very quick. He asked me if I can show the location or the person. I said I can clearly identify him, and even the money! He picked up his wireless and started talking into it, "Delta ...calling....### Delta.... Over" in some kind of code language. In couple of seconds another gentleman with stern eyes came to the counter and the GMR person asked me to narrate the event and walk with them. By then another young lady in jeans joined us. I asked them, "Who are you?" They said, "We are from the Vigilance Department". I narrated the event once again, and I led them to the counter. I identified the loader who had by then moved away from there to another counter area. 

The vigilance officer called him and immediately in a fraction of second plucked his Identity Card. The loader's name is Jai Singh Meena. Hei, now he cannot escape and run out of the airport! He was checked, and they pulled out the money from his pockets, and the money was identified and matched. Then we were taken to another counter. I was asked to give a written complaint. Meanwhile we were joined by two more officers one from the Jet Airways and another person, a senior officer, who said that he is the "Inspector". I was handed over the money and then I practically ran for the flight as it was time to catch up! 

Beware of Corruption in Airports and anywhere. Fight it intelligently. Take time to fight it. Do not shy away. We do have good officers who can respond to situations responsibly.