The 1979 Ramon Magsaysay Award for Community Leadership

BIOGRAPHIES of Rajanikant Shankarrao Arole and Mabelle Rajanikant Arole

RAJANIKANT SHANKARRAO AROLE was born in Supa in the Ahmednagar district of Maharashtra state, India, on July 10, 1934, the second child of Shankar and Leelawati Salve Arole. His parents were both schoolteachers and his father became Inspector of Schools. The Aroles raised their three sons and four daughters in the faith of the Church of England, inculcating in them Christian ethical and spiritual values that have guided RAJANIKANT through a lifetime of public service.
RAJANIKANT, known best by his shortened name RAJ, attended the Government Primary and Vidya Mandir schools

in Rahuri, Ahmednagar District, from 1938 to 1946, when he transferred to the American Mission Boys' School in Ahmednagar. That year a flood swept through Rahuri leaving in its wake widespread epidemics and hardship. The death of two of his classmates by plague left a deep impression on RAT, as did the lack of medical care to help flood victims. "For the first time in my life," he recalls, "I began to think of being a physician to serve these unfortunate people."
RAJ's concern for the poor was further aroused, as was his patriotism, by two brothers from Ahmednagar, Achhyutras and Raosaheh Patwardhan, who were at the forefront of the freedom struggle which culminated in the independence of India in 1947. Throughout his high school years (1946-1950) RAJ continued to be drawn to teachers and writers who showed great sympathy for their less fortunate countrymen; through one of them he was introduced to non-communist socialism. He was also influenced by the great Marathi author and humanitarian, Sane Guruji, whose books he describes as "very sensitive" and "filled with tenderness and concern for the downtrodden."

After spending two years in Ahmednagar College, AROLE went to Bombay where he completed the work for his Bachelor of Science at Wilson College (1954). He was then accepted at the extremely competitive Christian Medical College in Vellore, Tamil Nadu (formerly Madras state), where he earned both his Bachelor of Medicine and Bachelor of Surgery (M.B.B.S.) in 1960. While there he met fellow student MABELLE KAMALA IMMANUEL, a dynamic young woman who shared his dedication to public service and Christian ideals.

MABELLE, born December 26, 1935 in Jabalpur, Madhya Pradesh, India, was the second of three children of Rajappan D. Immanuel, a professor of New Testament Greek at the Theological Seminary in that city, and Beatrice Gunaratnampillai. Her parents were first cousins and came from an important family in Tamil Nadu which was "quite exclusive," with intermarriage among branches of the family the rule. They were third generation Methodist Christians.

It was from her father, to whom she was very close from earliest childhood, that MABELLE received her "deep spiritual insight" and her love of learning. A religious man, her father lived in a world of books, philosophy, study and learning. "He believed in the good there is in every man," MABELLE recalls. "He never spoke ill of anyone and I have never seen him lose his temper." Even though he led a sheltered urban life, he wanted his children to work for the poor in the villages. "It had been his desire to become a doctor," says his daughter, "and he hoped at least we, his children, would do so."

On the other hand MABELLE's mother was a "woman of the world," who handled the practical problems of family living. To this day she does not understand MABELLE's dedication to upgrading the health of rural India.

As a child MABELLE led a secluded life within the walls of the Seminary campus. She had few friends and her siblings—a sister nine years older and a brother nine years younger—were too far from her in age to provide companionship. Left to her own devices, she filled her time with books, music and handicrafts. Her joy in making things from whatever was available, rather than relying on expensive items from the shops, was to stand her in good stead in later years when she went to work in the villages.

MABELLE began her schooling in Jabalpur, first in Christ Church Girls' School and then in Johnson Girls High School. In 1950 she was sent back to her family's home state of Tamil Nadu to continue her education. She completed the two-year course at Holy Cross College in Tiruchirapalli in 1952, and went on to attend Women's Christian College in Madras where she earned her Bachelor of Science in 1954. Determined to fulfill her father's dream, she applied and was accepted at Christian Medical College in Vellore from which, like RAJ, she received her M.B.B.S. in 1960. A top student, she was awarded a gold medal in 1959 as "Best Outgoing Student of the Year" and graduated with first prizes in anatomy, physiology and medicine.

As medical students both RAJANIKANT and MABELLE took seriously the teachings of Christ and decided to work for the poor in the villages, where 80 to 85 percent of India's people live. RAJANIKANT spent his holidays working in Fairbanks James Friendship Memorial Hospital, a small 70-bed Marathi mission hospital in Vadala, a remote village in Ahmednagar district with a population of 1,200. This experience enabled him to learn firsthand both the problems of the rural poor and the practical skills needed to solve them—an exercise which helped him avoid the pitfall of accumulating more theoretical knowledge than was necessary for the tasks ahead. In this he and MABELLE were both encouraged by Dean P. Kutumbiah, whose clinical training emphasized the practical, human aspect of medicine. Kutumbiah taught his students to use their "head, hands and eyes and [do] as little laboratory investigation as possible" in view of the economic realities of rural India.

Equally practical in his outlook was Dr. Paul Brand, who specialized in reconstructive hand surgery for lepers. He helped RAJANIKANT and MABELLE understand that good surgical practice is not dependent on "a plethora of equipment in airconditioned theaters"; it depends instead "on one's ability to use the principles of good surgery anywhere, even under very primitive conditions." In addition to his practical instruction Brand deeply impressed the young students with his attitude toward people, and his Christian character. RAJ points as well to the commitment-of another professor, Dr. S. C. Deodatta, who, he says, "helped me to keep my vision of service to the downtrodden poor alive at all times and encouraged me to pursue the path I had chosen. [At the same time] his humility and simplicity kept me from being fanatical about my beliefs."

Both RAJ and MABELLE were supported in medical school by their respective churches and were expected to repay this support by contributing five years of medical service to a mission hospital of their denomination. On April 26, 1960, shortly after completing their internships, they married and moved to Kolar, in the adjacent state of Karnataka, to work as a team in the Ellen Thoburn Cowen Memorial Hospital for two and a half years to repay MABELLE's obligation. (In keeping with Maharashtran custom for the middle name of a man to be his father's first name or a variation thereof and of a married woman to be her husband's first name, MABELLE had dropped KAMALA and taken RAJANIKANT as her new middle name.) In 1962 they returned to RAJ's home state of Maharashtra where he was appointed superintendent of the Fairbanks James Friendship Memorial Hospital in Vadala where he had worked during his holidays, and MABELLE worked as a doctor. It was there that the young couple, who were attempting to serve not only Vadala but also a surrounding area of 200,000 persons, became aware of the futility of concentrating on curative medicine. Despite the best care they could provide, the villagers returned time and again with the same complaints—and 70 percent of their diseases were preventable with simple health care! Furthermore, for every patient treated, there were thousands who never found their way to the hospital. Many could not come because of financial or transportation problems. Others did not come for cultural reasons: they were not comfortable with sophisticated Western medical practices. The AROLEs came to realize, as RAJ says, that since the "traditional curative-oriented hospital system does not penetrate the communities . . . it fails to meet the total needs of the community."

At that time a fellow missionary doctor, Hale Cook, introduced them to the idea of community medicine. If the villagers knew more about simple hygiene and health, he pointed out, they would not need to rely so heavily—and so late—on doctors. They also began working with the government health services in family planning and in leprosy, smallpox and malaria control.

In 1965 their alma mater presented the AROLEs with the Paul Harrison Award for Health Work in Rural Areas, an honor conferred for the first time by the college. The following year RAJANIKANT received a Fulbright Scholarship from the United States government and the couple went with their daughter, Shobha, born in 1961, to the U.S. to study public health and to increase the skills they needed for work in rural India. From 1966 to 1969 they trained at the Lutheran and the Cleveland Metropolitan General hospitals—both in Cleveland, Ohio— where RAJANIKANT did his internship and residency in surgery and MABELLE her internship and residency in internal medicine. During their holidays RAJ gained practical training in leprosy treatment at the Leprosy Center, Carville, Louisiana, and in the treatment of tuberculosis at the National Jewish Hospital in Denver, Colorado. Their son, Ravi, was born in Cleveland in 1967.

After completing their residencies in 1969 the couple spent three months on an American Indian reservation in Arizona, and then moved to Baltimore, Maryland, where both attended The Johns Hopkins University School of Hygiene and Public Health. They received their Master of Public Health degrees in 1970. During that year they studied materials on rural health prepared by the Christian Medical Commission, an organization established by the World Council of Churches to help "direct previously hospital-centered church medical work towards more broadbased community health programs." With the help of the commission and Professor Carl Taylor, the AROLEs worked out an innovative plan for providing medical and particularly to the lowest 20 percent of the population which had "half the food and half the life expectancy" of the upper 10 percent. They left the United States with a pledge of seed money for their project from the United Church of Christ and the Christian Church.

The young couple landed in India in June 1970 and spent the next four months writing, traveling and talking with village leaders in Maharashtra, trying to choose the best location to implement their plan. They were seeking an area which fulfilled their five basic criteria. First, the section must be poor so that their project, if successful, could be readily adopted in any impoverished part of the country. Second, there must be few medical services available. Third, it must be a non-Christian region, where the gospel had never been preached. Fourth, the people must want medical care and be willing to work for it. And lastly, there must be no government plan for major industrial or agricultural development of the region. All of these conditions were necessary so that

they could evaluate their project accurately; they wanted to be certain that no extraneous factors could account for the change they hoped would take place.

The village leaders to whom they initially wrote had varied reactions to their proposals. In RAJ's home village the wealthy farmers who owned sugar factories welcomed the idea of a modern, well-equipped hospital for their own curative needs. In another area the community leaders were discouraged from continuing their dialogue with the AROLEs by an influential practitioner of traditional medicine. In other villages they were suspected of being outsiders hoping to come into the area to make money. In the end the AROLEs found Jamkhed taluka (sub-district), 300 miles southeast of Bombay, the most propitious site. The community leaders there were "enlightened and influential," and saw the political advantages of the program, as well as its benefits to the community.

The village of Jamkhed is in the Government of India's Kharda Community Development Block, which seeks to provide primary health care for 100,000 people. The health center in Kharda—14 miles from Jamkhed—had 2 physicians, 10 auxiliary nurse-midwives and 8 basic health workers. Each auxiliary nurse-midwife, located in a peripheral village of the block, was responsible for 10,000 people. Patients needing more sophisticated diagnoses, emergency care, or hospitalization were referred to a hospital 47 miles away at district headquarters. In addition there was a leprosy control unit for four community development blocks, manned by a physician, and leprosy technicians who identified and treated leprosy patients; the leprosy unit was not integrated with the general health services.

A difficulty with the government health plan, however, was that much of the money allocated to each block went for salaries, with the result that the program reached only about 12 percent of the target population. The AROLEs discussed their plans with the government staff beforehand, and pointed out that they hoped to reach the other 88 percent—the ones who did not or could not take advantage of government proffered services. They also reassured the practitioners of traditional medicine in the block villages, and sought to incorporate them into their broader preventive medicine/public health program. By 1975 the AROLEs proposed to serve a population of some 40,000 in 30 villages around Jamkhed.

Jamkhed was a logical place to make their headquarters. It is a market center, with government offices, banks, a high school, and with bus connections both to the town of Ahmednagar and to the surrounding villages. But the region is predominantly agricultural, with 88 percent of the people employed on the land, and very poor. One writer described Jamkhed as: "set in a strange, wild landscape of barren hills dotted with thorn trees. The soil lies like a thin worn-out coverlet over the rocky Deccan plateau. Rivers are few and each year they dry up long before the monsoon rains are due to fill them again." The area was at one time heavily forested, but during World War II the villagers began to cut down the trees for firewood, leaving the topsoil to be washed away by the rains. As a result, crops are meager and limited to certain kinds of millet and sorghum, dry soil crops that can survive for long periods of time without irrigation. These factors, coupled with an increasing population, left Jamkhed a food deficit area, qualified for the government Drought Prone Areas Program.

The villages around Jamkhed, as in most parts of rural India, were bound by a rigid caste system. In that region the major castes are farmers or cultivators (50 percent), and Harijans (20 percent), the outcaste untouchables, who are very poor—usually landless laborers—with no social status. Each village has an elected panchayat (council) and most of the leaders and decision makers come from the farmer caste or are schoolteachers or other educated government employees. Although the prime target group of the AROLEs was the poorest class, they knew they could not bypass the leaders or they would find them hostile and uncooperative.

They also realized they could not go directly to the common people because the people did not trust educated persons from outside their own village. This was due to repeated exploitation by outsiders, including doctors. After all, RAJ explained, even doctors with the best of intentions "expect to earn a scooter in the first year, a car in the second year, and a dowry in the third year."

Mission hospitals were trusted by the educated, but even here the masses misunderstood the motives of the hospitals and were afraid of being forcibly converted to Christianity. Therefore, on one hand, the feeling about Christian institutions made it more difficult for the AROLEs to begin their work, but on the other, the fact that they were Christians meant they were outside the local caste hierarchy and were acceptable—or unacceptable—to all castes equally.

From the beginning the AROLEs explained to the village leaders that if they wanted a health program they must take an active part in developing it, and in five years they must be prepared to take full responsibility for running it themselves. They also told them that the only money available was seed money; by 1977 the villagers would have to find their own funds to carry on. In short, their health would become totally their own responsibility.

After the AROLEs' first meeting with Jamkhed's leaders, a Jain farmer donated seven acres of land for a health care center. A vast, unpartitioned room on the second floor of a building facing the market square—with no electricity or running water—was offered as initial rental housing for the 20 staff members whom the AROLEs had brought with them. These nurses and paramedical workers were Christians, says RAJ, because we were there "to establish a Christian witness" as well as give medical care. They were a dedicated people prepared to put up with a great many inconveniences for low pay. For the first six months the AROLEs paid their salaries from money they themselves had saved in the United States. The town council, meanwhile, cleaned up a cowshed, which had been a former veterinary dispensary, for use as a clinic until the center was built.

At the end of September 1970 the Jamkhed Clinic of the Comprehensive Rural Health Project (CRHP) opened its doors on a six month trial basis. In the first three hours 300 people came, "on foot, on bicycle, in bullock carts, in someone's arms. They came with almost every ailment and disability known to man."

Although their goal was to address those diseases which were few in variety but many in number, and attributable primarily to malnutrition, water-borne infections, poor sanitation and "the traditions, the taboos and the social injustices that are meted out to certain weaker sections of our society," the AROLEs concentrated on curative services for the first three months because that was what the villagers wanted. They knew that no comprehensive health program was possible without the involvement of the people themselves, and that such involvement would not be forthcoming unless they first gained the villagers' trust.

These curative services were not performed free of charge. "We told them," says RAJ, "if they were willing to pay for these services, we would start with them. They all agreed to this; so from the first day we have been self-supporting as far as curative work is concerned." Patients pay three rupees (US$.37) per consultation. However about 30 percent of the poorest patients are not charged consultation fees and about 20 percent are not charged for medicines.

At first the villagers had some difficulty in accepting MABELLE as a doctor. In their experience women had no status and they had never before seen a woman who had studied medicine. Furthermore, coming from the south she did not speak Marathi (as did her husband) so the villagers thought, MABELLE says wryly, "this woman is so stupid!" Acceptance came only after her skills were proven.

Since her older sister, also a doctor, had moved with her physician husband to Canada, and her brother, an engineer, was residing in the United States, MABELLE's parents had come to live with her shortly after she was married. They joined the AROLEs again in Jamkhed, and her father, who lived just long enough to see the project established in the cowshed, was "very, very happy" that his daughter fulfilled his dream.

The pledged seed money was received and, MABELLE adds, "the United Church of Christ and Christian Church in the U.S. have continued their support through the years, monetary and moral, through their love, concern and prayer for our work. The support of Dr. Telfer Mook, secretary for India for both churches, needs special mention." In 1971-1972 the Christian Medical Commission in Geneva introduced the AROLEs to E.Z.E. (Evangelische Zentralstelle fur Entwicklungshilfe), a Protestant development agency which together with the Board for World Ministries also helped meet the capital expenditure.

Not being sure at the outset whether the project would succeed in terms of villager cooperation, the AROLEs built their medical center of metal sheeting so that it could be dismantled and reconstructed if they felt the need to move elsewhere. Jamkhed contractors donated their services free, and some building materials were locally contributed. The Seventh Day Adventists from Spicer College in Pune were employed to erect the hospital building. The hospital originally had 24 beds (later increased to 30), an ancient X-ray machine (not replaced until 1973), a laboratory, and an operating room to handle emergencies. Most surgical cases were sent to the Salvation Army Hospital in Ahmednagar, 50 miles away. Today the center handles 100 to 150 patients daily.

The X-ray machine and operating facilities were installed at the request of the program's Advisory Committee. This committee, whose membership represented different areas and different social groups within the region—e.g. women, Harijans, political parties—was responsible for establishing rapport among the CRHP and the villagers, the different levels of government and the local medical practitioners; deciding program priorities; and hiring nonprofessionals and community workers.

After the initial period of adjustment the AROLEs began to visit the surrounding villages of a late afternoon and have tea with their leaders in order to discover what they perceived as priority needs. "We believe," says RAJ, "that the local people are our best resource. . . . if we can listen to them, discuss with them, most of the problems that occur in villages can be solved."

But in their discussions the AROLEs found that health care was not at the top of the villagers' perceived-need list. Drinking water and food, in this drought and famine scarred land, came first, followed by employment, housing and education. Health was sixth. Knowing that health could not be isolated from other aspects of community development, and recognizing that sufficient food and pure drinking water would alleviate a number of illnesses, the AROLEs first addressed the villagers' expressed concerns.

To help obtain a pure and steady water supply the AROLEs enlisted the aid of several outside organizations. They persuaded the local government to do a geological survey of the area and AFARM (Actions for Agricultural Renewal in Maharashtra), a loose organization of development-conscious firms with drilling rigs which are made available on a fee for service basis, to install tubewells in 45 villages. The tubewells were financed by OXFAM (Oxford Committee for Famine Relief) U.K. and Christian Aid, the aid arm of the National Christian Council of Churches of the U.K. "Each village," reported RAJ, "wanted a well in the center of its village. However, it was known that Harijan sections of the village could not necessarily get access to the new well unless it was put in their section. With the consent of the local Advisory Committee, a water diviner was located who conveniently found that the best site for water in each village was in the Harijan section." To take care of maintenance, a man at Jamkhed was trained in pump repair and, for the sake of economy, the spare parts were stocked centrally at the health center. The benefits of this scheme became apparent in 1976 when cholera broke out in villages which did not have tubewells.

Knowing that children under five suffered the most from malnutrition or lack of food, the AROLEs pointed this out to the villagers and suggested that they could probably arrange for donations of milk and food from foreign agencies. But, they asked them, "what will you do in return?" Some promised to give money, others labor. RAJ helped them form committees which would be responsible for preparing the food, serving it and seeing that the children came every morning and received it.

An adult feeding program became necessary when the monsoon rains failed in 1972. In January 1973, with food donated by the United States government through the Churches Auxiliary for Social Action, the AROLEs began a food-for-work program, supplying 3 kilos of wheat and 315 grams of oil for each day's work. They stopped the program in villages where government projects were instituted, but continued it in others, even after famine conditions ceased. The food-for-work program emphasized preparing the land for increased productivity and conserving water when the rains finally came again. Projects included bunding, contouring and building water catchment basins and small (check) dams. At its height the program included 25 projects and became the blueprint for similar work by OXFAM on a worldwide scale.

The famine was a great social leveler, affecting rich and poor alike and disregarding caste distinction. Even landlords and village headmen had to work on relief projects as laborers beside the landless and the Harijans. And the AROLEs capitalized on the situation. In the long feeding lines it was simple to separate children by age rather than caste, forcing them thereby to mix. Another method was to ask each child to bring one cup of water for the common cooking pot. "Thus the brittle magic spell of caste was innocently and painlessly broken among the children," RAJ comments, "and once broken it lost much of its binding power."

After their immediate food and drinking water needs were met, the villagers were more receptive to the AROLEs' suggestion that they become self-reliant with regard to the children's feeding program. Accordingly they decided to set aside two or three acres in each village to grow the grains and legumes necessary for the "nutritious food supplement—a porridge of wheat, peanuts, other legumes, oil and milk." After much discussion it was proposed in some areas that irrigation wells be dug on the fallow land of one farmer in each village. Since that farmer would automatically "become rich overnight" by having water for irrigation, the advisory committees had to find farmers who would be generous—as well as likely to have water—for they were expected to donate some of the irrigated land for growing these protein-rich foods. One reason for the ready success of the CRHP in Jamkhed was that neither food nor water projects required major capital investment because of the availability of fallow land and underground reservoirs. In other parts of India lack of these ingredients may prove a problem.

In many villages the Young Farmers' Clubs (YFCs)—initiated by the AROLEs to get young people interested in developing themselves and their villages—became responsible for working the land set aside for the under-five feeding program. The AROLEs had begun these clubs by first encouraging the young men of the village to engage in volleyball games in order to break down caste restraints. From there they were led into discussing their common problems and into setting up a YFC. The YFCs in turn were encouraged to help organize community kitchens to supply food for the malnourished children, and later to identify fallow land and bring it under cultivation to grow food for the underfive nourishment programs. Over the years the activities of the YFCs have further expanded. In 1976 members planted 10,000 trees in the Jamkhed area, watering and caring for them until the monsoon rains. By October 1978 they had helped construct 100 check dams, leveled and brought under cultivation 780 acres of land and sunk and maintained 80 tubewells.

In 1971 and 1972 most children under five years of age were immunized in a mass campaign against diptheria, whooping cough, tetanus, polio, smallpox and tuberculosis. In setting up this campaign the AROLEs again insisted on the full participation of the community. "If you want your children immunized against disease," they told the villagers, "you will have to get 90 percent of them together for us. To have just a few children protected won't do any good." The success of the campaign meant that in later years it was only necessary to keep up with newborns, and since the birth rate was soon halved as an indirect result of the health program—families were willing to have fewer children since the health program assured them that their children would probably grow to adulthood—there were fewer immunizations. This kept the cost of the program down despite a sharp increase in the cost of vaccine in 1975.

During their first years the young doctors defined their specific fields of work. MABELLE became responsible for maternal and child care, family planning and general inpatient treatment. RAJ accepted responsibility for administration of the CRHP, field work and the treatment of leprosy and tuberculosis. They also set up their basic system of health delivery. They established a three-tier system, with the doctors and registered nurses at the center; a mobile team, made up of registered nurses, paramedical workers and social workers, which visited villages on a weekly basis; and village residents. At the village level the system originally relied on auxiliary nurse-midwives, but since their security in the villages could not be guaranteed, many left. Furthermore, there was a severe cultural gap between a city-educated nurse or paramedical worker and the illiterate rural folk.

The situation was resolved by finding women within the community, albeit illiterate, and training them as Village Health Workers (VHWs). This change was immediately successful. For example, in one village an auxiliary nurse-midwife who stayed for several months had not been able to convince a single woman to undergo a tubectomy— tying the fallopian tubes to prevent pregnancy. The VHW, on the other hand, was able to get 75 women to accept tubectomies within the same period of time. Therefore by 1972 most of the auxiliary nurse-midwives were replaced by VHWs.

The Village Health Worker is recommended by the panchayat and other influential village leaders, and appointed by the CRHP. The person selected must be an older woman, free of the responsibility of small children and other dependents, and able and willing to visit all homes in the village, regardless of the status or caste of their owners. She should preferably have had children herself so that she can identify with the problems of child bearing and rearing. The fact that she is usually illiterate is a help rather than a hindrance, because the poor, whom the CRHP is trying to reach, can identify with her as they cannot with an educated person, even of the same village.

VHWs come from all sectors of the society—from Harijan to Brahmin—having in common that they are active, well-motivated and respected members of the community. As RAJ has pointed out, in village societies women are normally relegated to a low position and given only unskilled tasks. Though capable of real achievement, they are not able to utilize their full potential. "Liberating these women itself is sufficient reason to make them health workers," he adds.

The VHWs undergo simple induction training for a week at the Health Center, and subsequently return to Jamkhed every Friday afternoon for an overnight training visit, during which time they report on progress and problems in their villages and receive further instruction. Fifty percent of the training program is devoted to motivation, because without proper motivation the VHW herself could soon become an exploiter in her village, selling her services and knowledge for a profit. The other half of the time she receives technical training. She is given an honorarium of 30 rupees per month, as well as 50 rupees for transportation and food while away from home.

The village worker receives a simple medical kit and functions out of a room or building set aside for her use by the village. She is trained to help with pre and postnatal care and simple deliveries; to teach or supply the simple water/salt/sugar solution to overcome dehydration resulting from diarrhea, formerly often fatal to small children; to seek skilled help when it is needed, and to lay the educational groundwork in family planning and public health. Her educational materials consist of simple flash cards and flannelgraphs. She keeps health records, usually with the help of a literate relative, and serves primarily as an information channel between the Health Center and the villagers, not as an expert.

The VHWs are supported by the mobile health units that visit the villages once a week and can evacuate emergency cases at any time. The mobile team, which resides at the center, provides immunization for major childhood diseases, medical follow-up, and pre and postnatal care; weighs children in order to detect signs of malnutrition; and checks for signs of tuberculosis and leprosy, and more recently, blindness. Like the VHW, the team is motivated through training sessions which spend equal time teaching skills and sensitizing the participants to social injustice and its damaging effect on individual and societal health.

Although their original plans called for serving a population, of 20,000 by 1973, that year the AROLEs, through their efficient three-tiered system, were already serving 40,000 people in 30 villages. They had, furthermore, achieved their goal of allocating roughly 70 percent of their time and resources to preventive medicine and 30 percent to curative. Their results were impressive. In the 30 villages under the CRHP mortality of the under-five age group had been cut by 50 percent and the killer diseases—whooping cough, tetanus and diptheria— had been almost totally eradicated by early immunization.

Programs had been started in family planning and for the control of tuberculosis and leprosy. In family planning the AROLEs proved that, contrary to expectation, village women can and will use oral contraceptives, since a careful and regular follow-up of their side effects is provided by the VHW. Some village women have even undergone sterilization. The family planning program is coordinated with, and funded by, the government primary health center.

CRHP health teams, meanwhile, canvassed the villages to locate and treat tuberculosis sufferers, who, initial surveys indicated, numbered 15 per 1,000 population. Persons afflicted with leprosy were known to number at least 12 per 1,000, though more were thought to have hidden their affliction for fear of being cast out of society as "dangerously contagious" or "cursed by God.'' To counteract these prevalent misconceptions the AROLEs adopted the policy of treating leprosy patients along with general patients, and of making it a point to touch them. In this way those whose symptoms had not yet reached the stage of deformity were less likely to try to hide their disease and were more likely to seek treatment. To help lepers whose disease had already disabled them regain self-sufficiency, the CRHP gave each six goats to raise goat is the meat of the area. By 1975 the AROLEs were treating 1,200 leprosy patients, or 30 per 1,000, indicating that their program was reaching beyond the confines of their 30 villages. Leprosy rehabilitation has been subsidized by the American Leprosy Mission in New York.

In the spring of 1973 MABELLE was invited by the American Medical Association in New York to speak on the Comprehensive Rural Health Project to a group of premedical students from Africa and Latin America, as well as from the United States. She is reported to have "fired them with possibilities opened for their work in their own lands."

In 1975 the AROLEs added the control of blindness to their objectives. The program includes prevention of vitamin A deficiency blindness in the under-five age group, cataract operations and conjunctivitis control. The cost of the program that year was entirely borne by the Blinden Mission of West Germany, a Protestant voluntary agency. It has since been incorporated in the locally funded general health program. With the backlog attended to only new cases now need treatment and preventable blindness is being covered by health education.

By 1976 the AROLEs had started to replace the registered nurse in their mobile team with auxiliary nurse-midwives. The latter, they found, were less expensive and more likely to stay than the RNs. "Delegation of every task to the humblest member of the health team capable of doing it satisfactorily," wrote RAJ, "is one of the ways of overcoming the problems of inadequate manpower and financial resources. And all staff members, including drivers and sweepers, are instructed in the rudiments of preventive medicine and nutrition because the poor, after seeing a physician or paramedic, will often turn for advice to someone they can better identify with.

Curative services at the Health Center, paid for by the patient supplied 66 percent of the running expenses of the community health program in 1976, the annual cost of which was Rs.400,000 (US$40,000) or Rs.5 per capita.

In 1977 the Karjat taluka of the Karjat Community Development Block, with another 40,000 people in 30 villages, was added to the CRHP scheme. The AROLEs are looking for a doctor to man the Jamkhed center so they can give more time to organizing the work in Karjat. In a departure from the original scheme, the plan for this new area, and for other parts of India where the Jamkhed program may be adopted, is to have a doctor perform medical functions only and to assign the design and supervision of the socioeconomic development programs to a trained social worker who would be administratively on a par with the doctor. According to the 1978 report of the Systems Research Institute (SRI) of Pune which did an evaluation of the CRHP for the United Church Board for World Ministries in India—and suggested guidelines for replication of the venture elsewhere—this is simply "an acceptance of the reality that most M.B.B.S. doctors are not trained social workers."

In 1978 and 1979 the CRHP began to train and organize other kinds of workers—e.g. veterinarians—at the village level. In addition selected members of the Young Farmers' Clubs were given specialized training as social workers to act as motivators in organizing new farmers' clubs and in coordinating the activities of various other groups. The YFCs also made a significant contribution in the development of large scale sanitation programs. Members are now engaged in educating their fellow villagers—using drama and folk art—on ways to solve health and social problems.

Because 1979 is the Year of the Child, the VHWs—who have also become "more dependable and competent as educationists, communicators and social workers"—are designing programs for total child development. And, "since children are inseparable from mothers," women are being organized into mahila mandals (women's groups) for economic and other activities.

The AROLEs have cooperated very closely with the government health programs in the area, particularly in family planning, immunization, and leprosy and tuberculosis identification and care. The government in turn has recognized the value of the work being done by the CRHP and has utilized services provided by it. Government primary health center doctors are sent to Jamkhed for training in tubectomies; all nursing students and matrons in the state come twice a year to learn how the center trains VHWs; the government uses villagers trained by the CRHP to build and repair tubewells in other areas, and reciprocates by supplying veterinarians and agricultural extension workers to train the members of the CRHP farmers' clubs and to help in loan schemes. Recognizing its own bureaucratic shortcomings, the government in 1978 asked the AROLEs to coordinate the building of housing in their area; so far 300 houses have been built under this arrangement. The two organizations have also cooperated in road building in the area, with the government supplying materials, the villagers the labor and the CRHP supervising and providing wages on a food-for-work basis. The AROLEs welcome this interchange, but do not seek government grants because they would then be bound by government regulations and supervision.

The central government has acknowledged the work of the AROLEs by appointing RAJ to the Indian Council of Social Science Research National Committee on Health Care, a 15 member board which makes recommendations to the central government on health planning and medical care for the nation. On this committee RAJ has led a fight against an increase in the number of medical schools in the country, urging instead a reorientation of priorities. As he points out, since independence the number of medical colleges has increased from 19 to 106, the number of graduates from 1,200 annually to 13,000, and drug production has increased in value from 700 million rupees to well over 800 million.

Producing more doctors and drugs—which society thought would automatically reduce the high rate of mortality and preventable illnesses—has not done so. Infant mortality in India even now is officially placed at 122/1000 as compared to only 10/1000 in Japan (although in Jamkhed it has been brought down to 40/1000), and preventable illnesses, like diarrhea, tuberculosis and infection, account for 80 percent of the deaths in the country. Furthermore professional care is still not reaching most rural areas; 80 percent of the doctors and 90 percent of the hospitals and clinics are serving the cities where only 20 percent of the population resides, and 90 percent of the national budget for health is spent in urban areas.

Therefore the great need, the AROLEs feel, is to change the emphasis in medical schools, encouraging service to the rural masses rather than the urban elite, and stressing public health and preventive care, rather than curative medicine. Young doctors, they say, should look at the "skill God has given them, not as a license to make money but as a great privilege . . . to serve people."

Another solution, they feel, is universal health care. "This can be possible," MABELLE insists, "if health care is made the responsibility of all, rich and poor alike." But they realistically recognize that people do not respect that which is given without cost. In all their projects they insist that the people be prepared to pay for, and be involved in, their own health care programs.

In 1976 RAJ was elected and has since continued to serve as chairman of the Emmanuel Hospital Association in Delhi, which administers 21 member mission hospitals in Maharashtra, Madhya Pradesh, Uttar Pradesh and Bihar. In 1978 he was chosen president of the Voluntary Health Association of India. Among other things the association produces picture books on health—e.g. Better Child Care and Better Care in Leprosy—which are translated into several Indian languages. Its slogan is "Health for all by the year 2000!" While it encourages people "to demand health services as a human right," it also agrees with its president that "people grow better when they are encouraged to do whatever they can for themselves." RAJ is also director of the Society for Comprehensive Rural Health Projects in India, set up in 1978 to act upon the guidelines drawn up by the SRI to start health projects similar to Jamkhed in other parts of the nation. MISEREOR (official agency of the German Catholic Church for Third World Development) in 1974-1975 had directly funded CRHP to build a center at Mahijalgaon, 17 miles from Jamkhed, for training personnel for other community health projects.

On the international scene the AROLEs have also gained recognition. The World Health Organization (WHO)—which identified nine projects in various parts of the world with worldwide potential and listed the CRHP as one of the nine—included a chapter by the AROLEs in its 1975 publication, Health by the People. RAJANTKANT AROLE is one of five members—and the only Indian—on a United States Agency for International Development (USAID) committee on primary health care and nutrition. MABELLE serves as a member of the Christian Medical Commission in Geneva, and a book, The Changing Role of Medical Personnel, published in 1978 by the Society for Health and Human Values, Philadelphia, U.S.A. (Ronald Mineur, ed.), is based on a paper given by her at a Bellagio Conference on Health and Human Values, sponsored by the Rockefeller Foundation.

Outside recognition has brought with it requests for help in training others. "At present," RAJ wrote in February 1979, "this is the most important aspect of our work" and has consequently created a substantial burden on the CRHP with regard to time and finances. UNICEF (United Nations Children's Fund), WHO and CARE (Cooperative for American Relief Everywhere, recipient of the 1968 Ramon Magsaysay Award for International Understanding for "constructive humanitarianism, fostering dignity among the needy in Asia and on three other continents for over 22 years") have sent village health planners from other parts of the world to Jamkhed for training. Workshops and seminars have been conducted for the Voluntary Health

Association of India and for medical students from various universities, with the AROLEs making a special effort to expose the latter "to the realities of rural life and to health programs among the poor." To date, over 600 Indians and about 150 people from other countries have received training at Jamkhed.

Now the AROLEs would like to find sufficient outside funding to set up a foundation capable of taking care of the CRHP's operating costs and salaries—particularly of qualified doctors. Thus relieved of the constant need both to raise money and to be present in the hospital at Jamkhed, they would be free to travel as consultants for comprehensive rural health care programs.

The AROLEs' daughter Shobha, 18, has just entered the same Christian Medical College that her parents attended. Their son Ravi, 12, is in sixth grade in Pune Hutchings School, a Methodist establishment where he has been a boarder for seven years. "The only bad thing about our work in Jamkhed," says MABELLE, "has been sending the children away to school from age five."

When the AROLEs started their work, one of their concerns was to establish a Christian presence in the area. Since it was very difficult for them to preach the gospel openly, they were content to wait until people asked them why they were doing this work and then explain their Christian motive. "One day," wrote MABELLE, "the leaders of Jamkhed came to us and said, 'We know now that you have come to us because of the cross. So you must put up a cross on top of your hospital building to tell everyone that you are Christians and that it is the cross that brings you here.' " The villagers themselves then designed and installed a huge lighted cross that shines at night "like a beacon in the sky, visible for 15 miles around. It is a constant reminder to both them and us," she says, "of the power of God in Christ, the power that brought us here." The government has also noted the commitment of the AROLEs and RAJ has been made an honorary magistrate of Maharashtra in recognition of his "moral integrity, uprightness and love for justice."

September 1979 Manila

REFERENCES :

Arole, Mabelle. "Village Health Workers and Community Involvement in Health Care Delivery in India" 1977. (Typewritten)

Arole, Mabelle and Rajanikant Arole. "A comprehensive rural health project in Jamkhed (India)," in Health by the People, edited by Kenneth W. Newell. Geneva: World Health Organization. 1975. P. 70-90.

Arole, Rajanikant. "An Alternative Approach to Rural Health Care: A Case Study," Janata (Adult Education and Rural Health Number). New Delhi October 8, 1978.

______. "Community Participation in a Community Health Programme," Journal of the Christian Medical Association of India. Mysore. Vol. 48, no. 4, April 1973.

______. "Comprehensive Rural Health Project," Contact. Geneva: World Council of Churches. No. 10, August 1972.

______. "Director's Report." Jamkhed: Society for Comprehensive Rural Health Projects in India February 28, 1979. (Mimeographed.)

______. "India: The Comprehensive Rural Health Project, Jamkhed." N.d. (Mimeographed.)

______. "The Village Level Worker, Comprehensive Rural Health Project, Jamkhed," Journal of the Christian Medical Association of India. Mysore. Vol. 49, June 1974.

Arole, Rajanikant S. and Mabelle Arole. "Comprehensive Rural Health Project, Jamkhed," Journal of the Christian Medical Association of India. Mysore. Vol. 47, April 1972.

______. Comprehensive Rural Health Project, Jamkhed, India. Proposal presented to the Christian Medical Commission, World Council of Churches, April 1972.

______. "Our Experience in Rural Health Service." Presentation to Group Discussion. Ramon Magsaysay Award Foundation, Manila. September 1, 1979. (Typewritten transcript.)

______. "Village Health Worker," Contact. Geneva: World Council of Churches. No. 25, February 1975.

Chhabra, Rami "One Profile of Hope," Indian Express. Bombay. March 24, 1979.

Djukanovic, V. and E. P. Mach, eds. "Comprehensive rural health project, Jamkhed, India," Alternative Approaches to Meeting Basic Health Needs in Developing Countries. Geneva: World Health Organization, 1975. P. 70-77.

Harnar, Ruth, et al. Teaching Village Health Workers, A Guide to the Process New Delhi: Voluntary Health Association of India 1978.

Joshi, D. C., J. G. Krishnayya and C. B. Das Gupta. Design of Voluntary Health Projects: A Case Study of the Comprehensive Rural Health Project, Jamkhed. Pune: Systems Research Institute. August 1978.

Mangalwadi, Ruth. "Liberated 'Netas' of Jamkhed," Light of Life Magazine. Bombay. August 7, 1978.

Mook, Jane Day. "Two Doctors Serve 80,000 People and Provide a Model for Health Care," A.D. New York. October 1973.

Sethi, Harsh. "Alternative Development Strategies," Economic & Political Weekly. Delhi. Special Number, August 1978.

Voluntary Health Association of India. "Report of the Executive Director." April 25, 1979. (Mimeographed.)

Interview with Drs. Rajanikant and Mabelle Arole and interviews with and letters from persons acquainted with them and their work. Visit to Jamkhed.