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Updated On: Thursday, 21 February 2019

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

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?

“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?

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

How did the concept come about?

“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?

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

This interview has been edited for brevity and clarity.

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