Posted by Ayesha Marfatia and Rachita
In 1989, Dr. Armida Fernandez set up Asia’s first milk bank at Sion hospital. She then went on to start SNEHA in the early 1990s with the aim to reduce maternal and neonatal mortality and gender-based violence. Routinely treating low-income families coming in with sick, premature infants, she wanted to develop sustainable interventions that would go beyond providing stop-gap solutions.
Dr. Fernandez then decided to transition out of her role at SNEHA – a feat very few founders manage. After retirement, the serial entrepreneur set up a palliative care clinic, and continues to actively participate in the improvement of public health services.
IDR: Dr Fernandez, could you tell us a little bit about yourself and your family growing up?
Dr. F: I was born in Karnataka, in a small place called Dharwad. It was a university town; there were no factories, just colleges, and lots of trees, flowers, and plants. I was the youngest of seven siblings. All my life I received so much love from family, friends and relatives. It makes you a different sort of person; I was really blessed.
My father was a professor of English and Latin. English Literature was my favourite subject. From Thomas Hardy to PG Wodehouse – I read every single book. My favourite subjects after literature were math and physics. But I chose to become a doctor because what would I have done with math and physics?
I got my MBBS degree in Hubli – just next door to Dharwad – and my postgraduate degree in Mumbai at KEM hospital, where I studied paediatrics. Later, I moved to Sion hospital.
IDR: What were some of your early influences?
Dr. F: The more I worked inside the hospital, the more I felt the need to get out of it, and work with these women to help them and their babies survive.
I remember an experience I had while I was at Sion hospital that upset me a lot. We had a six-week old baby that was raped. Six-week old baby! At the time, we were caring for 10,000 babies, we had teaching programmes. There were so many things happening all at once that we couldn’t follow up on the social issues of what had happened. Who was the baby with? Had the police intervened? It was then that I promised myself that when I got out of the hospital, I would work against violence.
Sion Hospital also had an entire ward for female burns. We had many women who came into the hospital burnt. The incidents were largely either homicidal or suicidal. When the women were asked for their dying declaration, they would flatly deny that anyone else had played a role in their ‘suicide’. They felt threatened and afraid; they worried what might happen to their children if they told the truth.
All of these experiences ultimately led me to do what I finally did at SNEHA.
IDR: It’s a very big step to go from being a doctor to setting up something as an entrepreneur. Could you tell us a little bit about the early days at SNEHA?
Dr. F: When I first started, I didn’t even know what a nonprofit was. I only knew that I wanted to work in the slums. Fortunately, someone from TISS who was working at the milk bank (that I set up while at Sion) helped me with understanding compliance, the rules and regulations of setting up a trust, and so on.
The early days were very haphazard – we had no idea how to run a nonprofit, but I have seen that when your intentions are good, you are honest and do a good job, things fall into place, and people come forward to fund you. I believe a superior power pushes us.
I had gone to a wedding and mentioned to my friend Neville Soans that I wanted to start this work in the slums; he said he had a house he was selling, and would give me the money from its sale to get started. The next day, he had a massive heart attack and passed away.
omen and children are most vulnerable – not only to illnesses, but to the social evils that surround them – alcoholism, drugs and violence.
A few months later, his wife Patricia, came to me with the money. She was now a single mother with five children between the ages of five and 15 to care for, but she still insisted that I take the money, because this had been her husband’s last wish. I told Patricia that we should go on this journey together.
With that money, we started SNEHA.
What was helpful in the early days was that given our prior experience at Sion Hospital we understood the Mumbai municipal corporation very well; we knew the strengths and weaknesses of the system. At SNEHA, we worked both with the municipal corporation to improve the quality of the system, and the communities to disseminate knowledge, and change behaviour. Most nonprofits back then would just do community work – our programmes worked with systems and communities in tandem.
IDR: And were the communities receptive when you first went into the slums?
Dr. F: We found that community mobilisation in slums was far more difficult than in rural areas, because in rural areas communities are more or less homogeneous. In contrast, working in urban slum communities is not easy; all of India lives in Dharavi.
Each street has people from different states and communities and families come with different traditional and cultural practices that influence their health seeking patterns. As a result, getting them together to form community groups was not easy. So, we decided to form ‘galli groups’ instead, because people knew each other in their gallis.
In order to change behaviour, we had to use various methods—house to house visits, forming women’s groups and slum committees that would influence others. We also had women as volunteers on our programme on violence; and it was amazing to watch these women take charge and bring about change in their communities.
When you’re working with communities, you also cannot expect results in a short period. It takes time to build trust. You have to get into the community, understand them, spend time with them. Today, if there is any problem, they contact us. But they have also become self-sustaining with regard to solving their issues.
We have a large number of women’s, youth and even men’s groups that have mobilised against violence. I remember some women were once getting harassed by some boys; they knew exactly what to do and how to proceed. You can really see the change, the way in which people have come together. There is so much empowerment there now.
IDR: You’re also very passionate about urban health. What are some of the challenges you’ve seen that are unique to urban areas?
Dr. F: People living in urban slums have a rough existence. Overcrowding, lack of drinking water, poor sanitation and ventilation are major hazards to health, and people living in slums are prone to infections and diseases that spread easily in these poorly ventilated homes. Women and children are most vulnerable – not only to illnesses, but to the social evils that surround them – alcoholism, drugs and violence. Besides, a majority of families are nuclear and have no extended family support.
For decades the country has focused on rural health and with the National Rural Health Mission (NRHM) there was a well-organised health system in place.
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When we started SNEHA in 1999 urban health as an organised system was non-existent. Later, urban health got integrated into the National Health Mission, but things are still happening too slowly. The urban population is growing so fast, health systems need to keep up. The government has plans, they’ve allocated budgets, but translating missions into action is a long-drawn procedure.
The challenges to urban health are many.
There is no organised system
While both private and public systems exist, they aren’t always present where the need is. Within the public system as well, certain areas have dispensaries, while others don’t.
The quality of health services is poor
Both public, and private health services—apart from those that are very expensive – have varying standards, and accreditation across hospitals is not uniform.
Entire sections of the urban poor are ignored
The newer slum areas are not recognised at all, neither are the pavement dwellers – they are the most vulnerable. The number of people that are left out of the health framework is far too large.
There are too many non-qualified health providers
Especially within slums. We call them quacks – their fees are negligible compared to qualified healthcare professionals, as is their quality of care, and the poor do not have access to private OPD health services, for varying reasons.
IDR: Going back to SNEHA, it’s probably one of the few nonprofits where the founder has handed over the reins to somebody else to run it. Very few people are able to transition like that. What was the process like?
Dr. F: I wanted to see what SNEHA would become, not after me, but in my lifetime. What I see happening everywhere is people hold on to their organisations until they die, and then changes take place that they may not have liked. This way, I can see what is happening with SNEHA, and bring about a change if I feel I need to.
It’s tough, expensive, and difficult, but to bring about change, you need to show people your research, show them what has worked, and what needs to be done further.
You also need to look at yourself and assess your strengths and weaknesses. If you want your baby to survive, you will make sure that the person taking over has strengths where you had weaknesses.
The transition was not easy – let me tell you. SNEHA was my whole life. But I had to step back completely. If I kept going back and lingering, it would be hard for the new CEO to take over. I think they’ve done a much better job than I did, because I was not a professional, I was still ultimately a dreamer and a teacher. This is something I would like to tell other nonprofits as well – the handover is important.
IDR: What have been some major learnings from SNEHA?
Dr. F: You have to work with both systems and communities if you want to impact the health of mothers and babies. From the beginning itself, we planned to ensure that this has been a continuous process, you can’t work with one and not the other.
You need to put in the effort. For our projects in nutrition and maternal health, we had to go door to door, from house to house, individually working with mothers. This costs more, and requires a lot of people, but if you do it right, everybody gets taught much better, and the results are amazing.
A life-cycle approach is necessary when we look at the health of women and children. Every phase of the mother’s life impacts the health and nutrition of her children, and the generation after that as well. We realised, as neonatologists, that we needed to go back all the way to the mother while she was an adolescent girl, to address newborn nutrition.
You need to do your research in a scientific manner to assess the impact of your work, in order to take it to scale and impact policy. We learned that if you want to change policies, you need to put in the research first. It’s tough, expensive, and difficult, but to bring about change, you need to show people your research, show them what has worked, and what needs to be done further.
IDR: So, what’s next for you?
Dr. F: I recently lost my only child to cancer. In her final months she was at home, and it wasn’t easy. There was no one advising me on what painkillers to give her, and how to make her more comfortable. I didn’t want others to go through what I did, which is why a year ago after I retired, my heart told me to start something for other families. So, I started a palliative care centre, where patients could have relief from pain, comfort care, and counselling to improve the quality of their lives.
We have had more than 250 patients in one year. We do home visits, with a doctor, nurse, counsellor, nutritionist, and physiotherapist, and they figure out how to make the patient as comfortable as possible. About 60 percent of our patients have now died at home, peacefully. And now that I’ve retired at medical director of Holy Family Hospital, I want to take palliative care to scale.
Ultimately, I think that everything in life is about love. Love is an echo. I got a lot of love, so I love a lot of people. If you love, you care. And if you care, you’ll do what you have to do.
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Today, I have no regrets. If I had to live my life again, I’d do medicine, I’d work in Sion Municipal Hospital, I’d start SNEHA.
Ayesha Marfatia is an analyst at India Development Review. At IDR, she handles research driven reports and curated content, in addition to writing and editing. Ayesha holds a BA in Sociology and Anthropology from St Xavier’s College, Mumbai.
Rachita is Co-founder and Director at IDR. Before this, she led the Dasra Girl Alliance, an INR 250 crore multi-stakeholder platform that sought to empower adolescent girls in India. She has a decade of experience, and has spent the past eight years working in the areas of financial inclusion, livelihoods and public health. She has led functions across strategy, business development, communications and partnerships, and her writing has been featured in the Guardian, Stanford Social Innovation Review, Next Billion and Alliance Magazine. Rachita has an MBA from Judge Business School at Cambridge University and a BA in History from Yale University.
This article was originally published on India Development Review and has been published here with permission.
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