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Simple solutions that save lives

Armida FernandezSociety for Nutrition Education and Health Action

Armida Fernandez was a professor of neonatology and, later, dean of Lokmanya Tilak Muncipal General Hospital and Lokmanya Tilak Muncipal Medical College in Mumbai. She is also a founder and trustee of the Society for Nutrition Education and Health Action (SNEHA), a nonprofit organization dedicated to improving health care for women and children in the slums of Mumbai.

The TakeawaySimple, low-cost innovations can yield dramatic gains. Instead of expensive technology, these solutions require only a deep understanding of the problem, a strong desire to create change, and a lot of common sense. Using this kind of thinking, Armida Fernandez cut infant mortality almost in half at a Mumbai hospital that serves the city’s poorest residents.

There’s no doubt that groundbreaking inventions and discoveries have moved the world forward, but sometimes, a small innovation can be just as powerful. I may not be one of the world’s great inventors, but I would like to believe I am among those who can innovate. To me, innovations are simple changes to existing processes. Finding them requires a deep understanding of the problem you’re trying to solve, a strong desire to bring about the required change, and a lot of common sense. It is the kind of thinking that can bring about quick wins in a resource-starved environment like the public hospital where I worked in Mumbai, which catered to huge numbers of the city’s poorest people.

I started there as a neonatologist, looking after very sick, premature babies. It was the 1970s, a time when public hospitals were starved for resources. We did not have the money or the equipment or the personnel to run a modern neonatal intensive care unit and as a result, babies were dying.

My team and I were determined to save these tiny lives—some weighing no more than 500 grams, able to fit neatly into the palm of our hands. I tackled the problem in a simple, logical, step-by-step manner. What I lacked in funding, I made up for in common sense.

I started by getting a precise understanding of why we were losing these neonates. The most common reason was infection. First, where were the infections breeding? Through a careful process of elimination, we arrived at the two most common causes. The first were the antiquated incubators in which we kept our babies. In Mumbai’s humid weather, without proper air conditioning, maintenance, or sanitizing, they proved to be a lush breeding ground for deadly germs that could easily overpower these vulnerable infants. It turned out, however, that disposing of an asset in the public health system was even more difficult than acquiring one. After much persuasion and the presentation of the evidence we had accumulated, we managed to get rid of the germ-laden incubators.

Then came the next challenge. These tiny infants needed warmth, and without incubators, we needed a quick, easily available, cheap way to provide it. The answer came while looking at our indigenous practices. As Indians, we were used to massaging oil on our babies. Oil traps heat in the body. So we began coating the tiny bodies with oil and wrapping them in locally available bubble wrap. That’s right, bubble wrap, the same plastic sheets used to wrap fragile items for shipping. If they required additional warmth, we used another locally available innovation: table lamps with bulbs of different wattage kept at scientifically calculated distances to provide just the level of warmth needed, as well as room heaters when the temperatures were low. These simple measures reduced mortality dramatically.

The second source of infections was the feeding bottles we were forced to use because the hospital’s protocol called for premature babies to receive formula. We discovered that breast milk was an easier and safer option. We encouraged mothers to come to the nursery and feed their babies and express milk for when they couldn’t be there. When mothers were not in the hospital or were too ill to nurse, my team persuaded the healthy mothers who delivered at this large hospital to donate some of their breast milk to save these tiny lives. Bottles were discarded, and easy-to-clean cups and spoons were used instead. This was just the beginning of a program that culminated with India’s first human breast milk bank. It was another simple innovation that once again dramatically reduced mortality figures.

The next most important challenge was insufficient neonatal care. Nurses trained in this specialty were in short supply and we simply did not have the resources for enough qualified, round-the-clock caregivers for these vulnerable infants. Again, a simple, common sense solution came to my mind. Who better to care for a baby than its mother? This insight led to the introduction of mother-friendly hospitals, where after a little bit of education, mothers were allowed into the neonatal unit to care for their sick newborns. They learned to clean and breastfeed their tiny charges, reducing mortality even further. These were just a few of the simple innovations that cut newborn mortality by almost half at the Lokmanya Tilak Municipal General Hospital.
Years spent caring for these babies convinced me that spending enormous sums—both monetary and emotional—to save lives in hospitals was important and necessary, but that it would be far better to make sure they didn’t end up there in the first place. And, once we saved them, too often we sent them back to an environment that was not clean enough or safe enough for them to grow and thrive.

This was the beginning of the Society for Nutrition, Education and Health Action (SNEHA), an NGO that I started in 1999. SNEHA works in the slums to improve the health of mothers so that their babies can be born healthy. It works through the existing health system to bring quality health care to the poorest of the poor in Mumbai’s teeming slums. Mumbai’s poor are often pushed below the poverty line during episodes of ill health. The poor have no access to health insurance, yet they often choose expensive, private care. Partly because patients pay for private care themselves, it is perceived as higher quality than the government-sponsored public system. The reality is quite the opposite. The quality of care in Mumbai’s private hospitals is visibly lacking. Poor patients often spend catastrophic sums for treatment, only to be transferred to a public hospital, poorer and most definitely sicker, once their funds are exhausted.

SNEHA chose to innovate by encouraging poor patients to choose the existing public health system from the start of a pregnancy or illness. Through a novel process of organizational change called appreciative inquiry, we looked at what was already working well in the public health system and sought to amplify those processes. And again, we worked to understand exactly why more women weren’t choosing the public health system from the beginning.

One important reason was that the maternity homes that provided care were too far from their homes. We persuaded the public health department to bring antenatal care closer to the slums. Antenatal clinics were set up within the health posts already present in every slum community.

Pregnant women who required specialized care during delivery were often shunted from one facility to the other due to a lack of expertise or equipment in maternity homes, often leading to delays in treatment and death. SNEHA worked with the medical staff in these facilities to develop standardized protocols that clearly laid out symptoms that should trigger a change in care and a process for referring patients in emergency situations to the appropriate facility. A doctor in a maternity home now knows when to refer a patient to a general hospital or to a tertiary care hospital.
Infrastructure was upgraded and vital equipment for diagnosing conditions and saving lives was provided to all facilities. Mothers and babies in Mumbai’s slums now are definitely safer in the hands of Mumbai’s large and comprehensive public health system.

In parallel, SNEHA works with women in slum communities, empowering them to access health care at the right time for themselves and their families. Our 100 strong team of “Sakhis,” or community health workers, go door to door, identifying pregnant women and malnourished babies and providing critical information on antenatal care, newborn care, breast feeding, and complementary feeding. A simple step like this can change the dynamic of how and when women seek care. Pregnant women are now better educated about prenatal care and childbirth and feel free to question the health care workers at their facility, for example, if they have not gained weight or if their blood pressure has not been recorded. Mothers now seek help if their baby is not gaining weight. A simple act of questioning has raised awareness and action.

Once those on the lowest rungs are encouraged to participate in the identification and resolution of issues, they become invested in the process and add to the spirit of innovation. These are conditions that lead to solutions that work. This, to me, is true innovation for the greater good.

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