By Abhishek Tiwari

The name CINI, or rather what the acronym stands for, is misleading for it conjures up images of missionaries embroiled in social work in some far off land mired in poverty. However, CINI, though full of dedicated hard working people, is not merely a social service agency or a place run by individuals responding to their divine calling. Public Health perhaps best describes the main function of this rather large organization that employs some 350 people. I was fortunate enough to work with some of these CINI folks during the summer of 1999. I came from the UCLA school of Public Health to Calcutta that sweltering summer eager, almost in a paternalistic way, to save the poor forgotten souls who were the beneficiaries of CINI's services. My experience there not only changed the way I conceptualized public health work, but also, more importantly, how I conceived my role in the international arena.

CINI was started by Dr. Samir Chaudri and two Australian missionaries in 1974 to provide medical and nutritional intervention to destitute children living in the 24 Parganas area in West Bengal. Over the next two decades CINI gradually evolved into the large public health organization - a veritable tour de force---it is today. Today medical services comprise just one aspect of CINI's activities, the bulk of which are focused on education, community building and training. At its main headquarters, a sprawling multi-storied facility located in 24 Parganas, CINI maintains a small emergency room, nutritional rehabilitation center, medical clinic, training facilities, library, computer room, dormitories, and a cafeteria; in addition this facility also houses its various administrative departments. Every Thursday some 600 women and children converge on the CINI campus for clinical advice and medicines. Normally medicines and doctor visits are available the rest of the week for a nominal fee, but on Thursday, perhaps because it is an auspicious day in Hinduism, both advice and drugs are dispensed free of cost. It is on this day that CINI's reach into the community and its potential for affecting positive change become readily apparent - one is left simply in awe at the throngs of women (and some men), almost all with children in their arms, waiting in line for medicines, pre-natal checkups, or a few moments with the physicians that staff the clinic. However, it is not these medical services that impart CINI its novelty or account for its effectiveness in improving the overall health status of its target population, rather it is CINI's unique public health approach, which entails case management, behavior change communication, and linkage building, that allows it to succeed where other more narrowly focused, myopic, organizations have failed. CINI's staff, or rather its staff's diverse professional background, is another very important reason why the organization continues to grow and is now considered a model NGO by the government and other younger non government organizations. In addition to physicians CINI employs sociologists, anthropologists, nutritionists, management specialists, statisticians, health educators, and public health professionals. The combined skills and expertise of these individuals have created an approach to health care that is holistic, culturally sensitive and cost effective.

CINI was recently recognized by UNICEF as only one of two non government organizations around the world having a holistic approach to the reduction of low birth weight incidence. Low birth weight, defined by the World Health Organization, as birthweight below 2500 grams (5.5 lbs) is a serious health concern in developing countries where incidence, the number of new cases per total live births, is often as high as forty percent. In comparison, developed countries usually have an incidence between five and eight percent. Low birth weight (LBW) increases the child's risk for morbidity (sickness) and mortality (death) significantly both in the short and long run. Low birth weight kids have a higher risk, vis-a-vis children born above 2500 grams, for developing cerebral palsy, neurocognitive and visuo-motor defects, diabetes, and coronary heart disease (among other ailments). These children, if they survive, pose a heavy economic, social and emotional burden to their already beleaguered families. Reducing the incidence of LBW in India would thus not only reduce the health burden of the country but also create a population that is more economically productive.

During the summer of 1999 I did a study for CINI on the correlates of low birth weight. The idea was to find those factors that most impinge on birth outcome in CINI project areas. Ultimately the data from my study and other more longitudinal studies, to be done in the future, would be used to create a health intervention that not only worked, but also was also resource sensitive. The study involved interviewing some 35 women, at their homes, about their food consumption habits, work/stress, medical history and hygiene. Additionally, I also took a few anthropometric measurements (i.e. weight, height, head circumference) and blood pressure. Using this information coupled with birth outcome for each of these women we were able to come to some tentative conclusions about the factors most relevant to low birth weight in CINI project areas. The preliminary data seems to indicate that any significant reduction in low birth weight incidence will only be achieved if pre-pregnancy height and weight are increased. A large number of women in India are going to produce low birth weight children despite good prenatal care, adequate food consumption and proper rest during pregnancy because they are simply too short and underweight. Weight for height, often measured using the body mass index scale, is a very powerful predictor of birth outcome of most women in India, according to the BMI, are too undernourished to produce healthy babies. Thus, any reduction in LBW incidence will require targeting these women long before they are pregnant.

The work I did this summer at CINI was by far the most rewarding endeavor I have ever undertaken in my life. The work was not only exciting but also extremely rewarding and inspiring. Most women participating in the study were very young (17-20) and lived in circumstances unimaginable to most in developed countries. Usually they lived in one bedroom, mud dwellings, without proper bathroom or kitchen facilities. Most bathed in one of the many ponds adjacent to their homes. Cooking was done in earthen stoves located outside the house. However, surprisingly many had electricity, though most of it was procured illegally, and a few even had tape decks. Despite their conditions a lot of the women I interviewed appeared happy and were very accommodating to my queries. The only reason I could even see these women was because of the rapport CINI had built with the community over the last twenty five years. Usually women in rural India are inaccessible, especially to males, during the last days of their pregnancy.

The most profound experience I had at CINI was when I interviewed Brishpati Mondol. The following excerpt from my field notes perhaps best describes her situation:

This is probably the saddest case we have had so far. Her husband is a drunk who goes out to work maybe 2 days a week where he earns about Rs.30/day. She hasn't eaten all day today and is understandably hesitant to answer our questions. Despite her circumstances she manages a smile and can be cheerful. These sentiments however belie a deep sadness.

Just a few months before this pregnancy her last fetus spontaneously aborted at 3 months (probably due to internal bleeding because of the beatings inflicted upon her by her husband). 2-3 months after this tragedy she became pregnant again with her current child.

Brishpati despite her circumstances seems remarkably strong and resilient. However she is not able to eat properly and maybe eats twice a day (if she is lucky). The quality and quantity of her meals is poor at best. The neighbors gave her some Muri, which she accepted reluctantly, because she has not eaten today.

Her house is made out of mud and has no electricity. We had to do the interview in her neighbor's house because hers is in really bad condition because of flooding. During this pregnancy the only ailment that befell her was diarrhea.

Brishpati was eighteen at the time of the interview. Just a year and a half ago she was a teenage girl, living happily with her parents, getting three meals a day, without any worries, without suffering. Her current reality is, as is apparent from my notes, radically different. I was amazed by her strength, saddened by her circumstances, and angered by my inability to do anything about it. I wanted to give her money, food - I wanted to take away her pain. But I couldn't. At that point I could not help but feel that I was somehow prostituting her and others in my study by using their narratives, their pain, for a study, the results of which would probably not improve their situation immediately. There are millions of Brishpatis out there in India and in other developing countries, all of whom face a future that is uncertain, full of suffering and, in many ways, ineluctable. Her story was a powerful reminder to me of how health problems are embedded in culture and cannot be divested of their social reality - any approach that simply tries to reduce a health problem, especially in developing countries, to biology is misguided and ignorant.

On a quirkier note I also had the dubious pleasure of encountering snakes, flooding and bombings during my stay in Calcutta. On at least two occasions during the filed work we came within a feet or so of rather large snakes. Also since I was there during election time - an event the Bengalis take very seriously - political tension was rather high. On one occasion a few gentlemen took it upon themselves to scare supporters of the opposition party by lobbying a few bombs into the local clubhouse. There was no real damage or injuries; additionally most of the CINI staff seemed inured against the incident (but I wasn't!). Lastly there was the flooding. On several occasions during the field work I was unable to interview a few women because the road had washed away because of the monsoons. On a couple of occasions, sadly, some of the women scheduled to be interviewed had lost part of their home to the rain (that is the reality for many of the individuals living in rural India). During the last two days of my stay Calcutta experienced the second highest amount of rainfall in its history. The streets were flooded and most places, including CINI headquarters, were inaccessible (for this we could thank the incredible drainage system of the city of joy). However, despite the mishaps and mis-adventures the experience was thoroughly enjoyable - something out of the pages of national geographic at times!

CINI's strength lies in the fact that it has recognized the multiple determinants of health. Its approach is neither reductionist nor paternalistic; instead of building dependents CINI has sought to empower communities and women to affect their own destiny - in this sense it is more of a facilitator than a provider. Change is useless if it is not sustainable. Recognizing this truism CINI has consistently sought avenues for change that are not only viable in the short run but more importantly lasting in the long run. Perhaps the most positive characteristic of the organization is its capacity for self-reflection. Led by people like Samir Chaudri and Kali Pappu CINI is constantly evaluating itself and its activities in an effort to hone its program methodology and subsequently get the most for its resources. What I liked most about the organization was that its top administrators were very approachable and had enough faith in me to give me the necessary latitude to do my job properly. Many Indian organizations, both private and government, get mired in a bureaucratic morass and hierarchy-ego politics that leave them essentially effete. CINI, fortunately, continues to rise above such internal power games, probably one of the main reasons for its success.