Q&A: ‘There is a silent rejection’ of large health interventions

This article was supported by The Rockefeller Foundation Bellagio Center.

A community organisation in the Indian state of Uttar Pradesh is challenging how health organisations typically go about their work in poor parts of the world.
 
“The dominant paradigm has been that we need to develop these solutions [in] elite environments and then transport them into the communities,” says Vishwajeet Kumar, founder of the Community Empowerment Lab. “I have a very different take.”
 
In this interview, part of the Bellagio Residency 2018 series, Kumar tells SciDev.Net about the Lab’s philosophy and how putting it in practice has helped sharply reduce neonatal mortality in rural India.
 

How does the Community Empowerment Lab work?

 
We have four stages of work. The first stage is deep listening, with deep empathy – without bringing our own mental models, trying to understand why do people do what they do, think the way they think. The second is essentially co-design: we sit together as a community ‒ both the science and the local wisdom ‒ where we can have a free and fair meeting and mating of ideas. The third step is to actualise it. So we evaluate what we have developed through randomized control trials in general, and sometimes other quasi-experimental studies. [It] essentially means the results would get published. If we have the proof of principle here, then the fourth state is essentially working to bid [to] governments and policymakers, to see how we can integrate that within a larger scale.
 

What’s an example of how this has helped?

 
I used to be at Hopkins [Johns Hopkins University] and I came back to India, into this rural community. The first thing we did was epidemiological studies. And we discovered that whatever statistics were available, the mortality rates of children were actually at least 25 per cent higher. At that point, 15 years back, the community health centre was extremely weak. The mortality rate was 8per cent. When I look at it biomedically, I feel there are a lot of things they [people] do [that are] putting the babies at risk. But then we have a convergence point: that we both want to save lives – and can we bring science to add to what they are already trying to do [to save 92 per cent of the babies]. We don't have to replace, we just need to build on their local wisdom.

“The best milk is not produced by a doctor, is not produced by Nestle. It is produced by the poorest mother, as well as the richest mother”

Vishwajeet Kumar, Community Empowerment Lab

So we developed a whole package of essential newborn care interventions around this. We brought in some science, in terms of what we call behaviour change management. I would actually call it empowerment. We did a randomized control trial and found a 54 per cent reduction in neonatal mortality, which we published in The Lancet. This was [in a place] where there's no medicine. This is the potential within the communities, the mothers themselves. We just don't need to see them as a demand-side, and ourselves as a supply-side, but they all are producers of good health – we need to recognize it.
 

In that philosophy of putting the person first, how do you evaluate – medically or scientifically – what is valid to follow up on?

 
Many at times I feel there are solutions looking for a problem. We're saying, can we reverse it? For instance, when we studied newborn care practices, we realized [that] when the baby is born it is bathed immediately, and their vernix is scrubbed and removed. Now, is it harmful? It is biomedically a harmful practice – the vernix is essential, protective, and it shouldn’t be removed. By bathing the baby, you are putting the baby at the risk of hypothermia.
 
But why do people do it? Well, they do it because they actually believe that nine months of pregnancy is nine months of accumulation of dirt, because it is nine months of amenorrhea [missed menstruation], and they believe they need to cleanse the baby. Bringing [in] epidemiological tools, we realized most of the babies die in the first day, and in the first week. The first week also coincides with the seven days they [mothers] will stay in a closed room, and they have very limited care seeking once the baby is sick.
 

“If I am a doctor, trained in a certain biomedical model, I've never been trained to also be appreciative of the cultural model that exists in the community.”

Vishwajeet Kumar, Community Empowerment Lab

Once we have it [the understanding] we develop an intervention around it. So one, for example, could be around hypothermia ‒ we coined a term [for] the cold fever that puts the baby at risk, but you can manage that cold fever by putting the baby … skin-to-skin. Then of course we will evaluate – assessing on the mortality, morbidity, weight gain etc.
 

Is it community health workers that interact with the people involved?

 
Yes. And now they have become part of the larger health system in India. When we started we didn't have a health worker cadre, but I believe we did provide the scientific evidence that health workers can play such a very important role.
 

And is this what you meant by a process of ‘enculturating science’ when you proposed a 2016 residency at Bellagio?

 
If I am a doctor, trained in a certain biomedical model, I've never been trained to also be appreciative of the cultural model that exists in the community. And usually, there is no interaction. We need to weave them together, and we need to bring the best of the West and the best of the East. So hypothermia could be a biomechanical concept, but how do I translate that into something that they [people] can appreciate and integrate within themselves.
 

How did the concept come about?

 
I was born in one of the most impoverished parts of the country, the state of Bihar. I spent the first five years in the village, and then raised by my eldest brother who was a virologist. I got to travel with him around the world [and] kept going back every year. I was at this intersection of two worlds who were not talking to each other. Maybe that is one part of it.
 

“Physicians are trained to have absolute control over their patients. I think we need to be humble, to say well, I may know something but mothers also know.”

Vishwajeet Kumar, Community Empowerment Lab

The second part is, it’s ethical and moral and smart that we have the larger set of people become part of the solution rather than the problem. If we look at the global failure of behaviour change programs, or larger government interventions, it seems to me there is a silent rejection of these. And part of this rejection is because we don't even begin with them in mind – we begin with a problem in mind.
 

Are big organizations that promote health policy receptive to this sort of approach?

 
It has not been easy. One reason, I believe, is this very top-down ‘I know the answer’ [attitude]. Physicians are trained to have absolute control over their patients. It is only more recently that now there is some gradual change. But still, very gradual. Let me give an example of breastfeeding. The best milk is not produced by a doctor, is not produced by Nestle. It is produced by the poorest mother, as well as the richest mother. But we don't see them as co-producers of that health. I think we need to be humble, to say well, I may know something but mothers also know. We historically have been very interventionist.

The second piece of it could simply be that a lot of the development comes from largely an agenda driven by developed countries, and therefore they come with either a sense of charity or a sense of superiority. That is not just a West versus East [issue], but within the country.
 

What is a concrete step towards taking a similar approach in other parts of the world?

 
I think the first step simply has to be, let’s listen. Let’s listen to the ‘beneficiaries’, and let’s ask them how they would go about doing it [solving a problem]. It can be difficult! But if you want to, I think it’s not too difficult.
 
This interview has been edited for brevity and clarity. 

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This article was supported by The Rockefeller Foundation Bellagio Center. For nearly 60 years the Bellagio Center has supported individuals working to improve the lives of poor and vulnerable people globally through its conference and residency programs, and has served as a catalyst for transformative ideas, initiatives, and collaborations.



From November 5 – December 3, 2018, the Bellagio Center hosted a special thematic residency on Science for Development, with a cohort of up to 15 scholars, practitioners, and artists whose work is advancing, informing, communicating, or is inspired by the use or design of science and technology to address social and environmental challenges around the world.