Visionary tactics

Before it could treat eye disease in Mumbai a charity had to use other means to gain the community’s trust

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Standing amid a throng of curious children in Mawle Nagar, a chaotic slum in the north of Mumbai, I am faced with a conundrum.

I have spent the afternoon being guided through a series of projects by Gopa Kothari, a paediatrician with expertise in the prevention of child blindness who has spent three decades working in more than a dozen of the shanty-ridden communities that dot India’s financial capital.

Dressed in an elegant yellow sari, she has taken me to visit improbably tiny “micro-skill” classrooms, where young women learn to embroider and produce decorative arts, and to home-based cooking businesses and workshops on the best ways to sterilise water.

But while Kothari’s charity’s is called the Child Eye Care Charitable Trust, almost nothing we have seen has anything to do with children or eyesight.

“When you enter a community you have to have a dialogue with the leaders of the community, who often feel people come to exploit them,” she says, when I ask why her organisation backs such a hodgepodge of ventures. “The entry point has to be their needs, not yours.”

What Kothari wants to talk about is xerophthalmia, or dry eye syndrome. The condition causes permanent blindness in tens of thousands of malnourished children across the developing world each year, despite being easily preventable with vitamin A supplements, or even a cup of spinach or a few carrots, three times a week.

Our visit to Mawle Nagar is just one scene in a bold 30-year experiment in which Kothari’s organisation has moved from slum to slum, trialling new ways of persuading residents to prevent the condition themselves. It is a journey that has convinced her of one simple message: help people with what they think they need first. “Once you have established a good rapport,” she says, “you can talk about what you want to talk about.”

Kothari’s experiment began in 1981, as India’s political leaders searched for ways to reduce the nation’s 40,000 cases of xerophthalmia each year. Progress was slow. Numerous large-scale government health programmes had tried to offer vitamin sachets to slum children, while exhorting their parents to eat more healthily. These efforts worked for a while, but when the health workers left, the blindness rates rose again.

After a summit meeting in New Delhi Kothari was asked to head a pilot project to test different approaches. Its location was to be one of the world’s largest and most challenging slums – Dharavi, which today houses around 1m people on 540 acres in mid-town Mumbai, making it one of the world’s most densely populated habitations.

The situation she found was grim: 8 per cent of children in the area weighed less than 60 per cent of the average for their age, their undernourishment placing them at severe risk of blindness. Yet many parents needed special convincing: attacks of blindness were often seen as the work of angry gods or evil spirits, she recalls, to be treated by ineffectual faith healers or herbal remedies. The educational materials used by previous projects often proved ineffective too; many featured pictures of African women, which made little sense to mothers in an Indian slum.

Kothari dreamed up posters more suited to local tastes. One featured Ganesh, the pot-bellied Hindu elephant god, holding blindness remedies in each of his seven hands. Another played on patriotism, featuring an image of India’s national flag, but with its green and orange stripes replaced by spinach and pulses.

These materials were put to work as part of a broader programme educating parents about health and nutrition, while providing vitamin supplements to their children. Elsewhere, local shopkeepers were encouraged to sell dark-leafed vegetables, while training schemes in crafts such as sewing and basket-making helped to boost incomes. Those who needed specific medical help were taken to a nearby hospital.

The three-year pilot was hugely successful: severe child malnutrition dropped from 8 per cent to 1 per cent, while child blindness fell sharply too. Buoyed by the success, Kothari decided to expand the programme, and it was at this moment that her experiments began in earnest.

“When we first enter an area, we will do a survey and find there are children who are anaemic, mothers who are malnourished, people who need cataract surgery, so you know healthcare and eye-care is required, which is our domain,” she explains.

“But if you ask people what they think, they will come out with all sorts of things – except for health. For them, water might be a priority or getting a good hut or increasing their income.”

It was in 2003 – more than two decades and a dozen slum projects later – that the trust first looked at setting up its operations in Mawle Nagar, a mostly Muslim area with a population of around 13,000, crammed into a small patch of land about 20 minutes north of Mumbai’s international airport.

Early discussions threw up a range of problems, most prominently about limited water supplies and dirt roads; as usual, no one seemed to care much about eye problems. “Luckily for us there was an election coming up,” she recalls. After pressure was brought to bear on vote-hungry politicians, the quality of water and roads suddenly improved.

It was only after this that the trust could push its own agenda: talking to mothers about nutrition and organising health camps with doctors to provide treatment. But their most popular contribution, as in many other slums, turned out to be a series of “micro-skill” classes, in which they trained local women as teachers, on condition that they ran classes for others.

The trust formally left Mawle Nagar in 2008 – its projects run typically for around four years before being handed over to the community – but these classes were still going strong when I visited, on a damp late monsoon afternoon in August this year.

In one tiny classroom I found about 20 female students learning traditional sewing skills, presided over by Shabina Munna Sheikh, a 21-year-old who became certified as a tailor with the trust’s help five years ago.

“I used to sit at home, totally useless,” she says, in front of her class. “When I started teaching I felt much more confident and good about earning something for my family. I now make about Rs3,000 [$54] a month.”

A similar, positive effect is clear in a second makeshift classroom, where Rubina Shahnawaz, 20, teaches painting and decorative henna techniques. She giggles at the mention of taking driving lessons. “I always had an interest in art, both in learning and teaching it,” she says. “The next class I want to take is driving, precisely because in our community it is not really allowed for girls.”

The sometimes oblique link between such classes and eye care also becomes clearer. “The trust made announcements for days before it set up a camp where it offered cheap eye exams, advice and medicines,” Shahnawaz says.

“My mother had cataracts but had surgery after a doctor at the camp advised her to do so. Now we all have knowledge about how to take care of our eyes.” The students nod politely when asked if they know of Kothari’s work on child blindness; one even says, with a knowing smile, that she eats plenty of carrots.

The slum is an example of a model that, despite its limited scale, seems to achieve results. In all the slums in which the trust worked between 1981 and 2011, child blindness rates fell substantially. More importantly, when it handed its work over to the community, rates stayed down.

“Some non-government organisations can end up being quite destructive,” says Matias Echanove, an expert on urban planning based in Dharavi. “Their relationship with the local community can be very political and very difficult. But if you work through existing organisations and power structures, without entirely buying into them, you can get round some of this.”

But for Kothari, it is the simplest lesson that resonates most deeply. “Have you got to the underlying causes?” she asks.

“Today you have dealt with one child, but another will come along in a few years. To do this you have to find ways to hand over to the community. It is the only way.”

Additional reporting by Kanupriya Kapoor

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