Thirty-four-year-old Amala is animated and humorous, bursting into occasional raucous laughter as she describes her life. We sit in her tiny home, a hot, one-room dwelling in Karimadom, a poor neighborhood in Trivandrum, the capital city of the south Indian state of Kerala. Amala is a single mother with two children ages 12 and 13. She is a confident, warm woman who works as a volunteer for Kerala’s Health for One Million (HOM) program.

“Health care is more important than disease cure,” she exclaims, stating one of the guiding principles of HOM. She and hundreds like her are the backbone of a remarkable primary health care program providing medical care to more than a million people in Kerala.

“We want our health services to take primary health care to the masses,” said India’s Catholic bishops in 1978.

This mission inspired the late Lawrence Mar Ephraem, then the Auxiliary Bishop of the Syro-Malankara Catholic Archdiocese of Trivandrum, to begin the HOM program.

To support this ambitious program, Mar Ephraem enlisted the support of the Bethany Sisters, a Syro-Malankara Catholic religious community of nuns who combine Eastern Christian monasticism with the essence of Indian spirituality and an active commitment to serve the poor.

“The enjoyment of the highest attainable standard of health,” states the constitution of the World Health Organization, “is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” Health is a basic human right that usually falls short of realization in countries like India. Zones of urban blight have developed in what was once rural Kerala – open drains, lack of latrines and safe drinking water, muddy puddles breeding mosquitoes, shanties tacked together with scraps of plastic and cardboard, unemployed parents and hungry children. More children in these areas die of easily preventable ailments such as diarrhea than from any of the more serious diseases such as malaria or tuberculosis. Primary health care, with its emphasis on prevention and early detection, is the answer to this alarming problem.

As Amala leads me through the muddy alleys of Karimadom, she explains HOM. The program works primarily through women who are trained in primary health care and encouraged to take responsibility for the health of their communities.

The HOM worker is a volunteer in the truest sense of the word. Any mother who is interested in her community, able to communicate her knowledge to others and willing to volunteer roughly two hours each month may become a village or neighborhood worker. The primary volunteer position is the “mother leader,” who is responsible for 10 families in her community. The families choose their mother leader on the basis of a volunteer’s organizational and leadership abilities. Amala is one such volunteer.

Amala introduces me to some other mother leaders, and I am given a demonstration of a typical house visit. During one visit, Amala and the mother leader demonstrate how a preparation of one part salt and ten parts sugar mixed into a glass of boiled water makes an excellent treatment for diarrhea. Known as Oral Rehydration Therapy, this is a simple cure and is widely used to treat young children with diarrhea. Now a life-threatening condition in babies may be cured by virtually anyone at minimal cost.

Other aspects of health awareness are promoted by HOM’s trained volunteers. Health and nutrition education help to increase the weight and maintain the health of young children, whose growth and progress are monitored on charts. Mother leaders meet every few weeks, learn about the nutrition qualities of local foods and, when possible, encourage the planting of small kitchen gardens.

As a result of this comprehensive nutrition education, more HOM beneficiaries are eating nutritious foods such as tapioca (the protein-rich leaves as well as the starchy tuber that grows underground), green leafy vegetables, papaya, sprouted cereals and pulses (the edible seeds of certain plants).

Radha works as a HOM organizer in Kadakkal near Trivandrum. She describes her first encounter with the program:

“One evening, about 15 years ago, I was going to the market to buy provisions. I was expecting my first child. There was a Catholic sister visiting my neighborhood in Adaymon. She was talking to a group of women about the need for eating leafy green vegetables during pregnancy. I was curious, so I stopped to listen. Since then I have attended every meeting.”

HOM encourages mothers to breast-feed their children, since breast-feeding strengthens their immune systems, and to ensure that the children are immunized against infectious diseases. National and local governments have recently become active in immunization programs and HOM has been helpful in promoting awareness. HOM projects also stress the benefits of safe drinking water; volunteers have installed wells with hand pumps to cover this need. HOM has also aided in the construction and use of latrines for those living in these poor neighborhoods.

“An important objective of HOM is to make every beneficiary an agent of health and development,” explains Sister Eymard, a Bethany Sister who directs HOM. As a result, they have developed an excellent communication system through all levels of the program. Every volunteer has a voice and each individual through an election process has a chance to rise through the system.

“Health for One Million is the quintessence of voluntarism and self-reliance,” says Sister Eymard. “Founded on these two tenets, HOM is operated by the community for the community.”

Yet, as Mar Ephraem once stated, “a project that begins with money cannot survive without money.”

HOM does not depend on external grants for its day-to-day activities. Occasionally, however, the program accepts grant money for specific programs from organizations such as CNEWA.

The work of a HOM volunteer is selfless. “The role of the health worker is considered more of a service to the community for which the community pays rather than as an employment by HOM authorities,” says Sister Eymard.

“The community may, if it so desires, pay a remuneration to the HOM worker as a token of gratitude.” In addition, self-reliance is central to the effective HOM strategy, and beneficiaries pay a tiny sum each year.

In its holistic approach toward development HOM recognizes that one of life’s necessities is a steady income, and for the poor this is often achieved through small business enterprise.

To that end, a revolving fund is arranged from which small, short-term loans, called seed money, are available for families to start their own income-generating projects. Small businesses such as bee-keeping, tailoring, mat weaving, animal rearing, kitchen gardens, mushroom cultivation and small shops have become viable projects for many HOM beneficiaries.

The program has successfully found its way into rural areas as well as urban. In the village of Chakkamala, two Bethany sisters provide physical as well as spiritual guidance to the poor of that area. Most of these people resettled in Chakkamala after they were evicted from an area near Trivandrum, which was cleared for an airport. Some 40 miles away, they found themselves in a stony, mountainous region where only rubber trees grew.

HOM came to the rescue. The two sisters aided these locals in the construction of contour terraces, or bunds, which inhibit erosion of the dry land. They helped in the construction of wells and latrines, conducted agricultural seminars and ran mobile clinics and environmental camps. Today these Bethany sisters run a child care center to help working mothers; they also use the center to hold meetings for mother leaders.

Health for One Million faces additional challenges in more remote, tribal areas. Hansens disease, or leprosy, is still prevalent in these parts of the country, but HOM is dedicated to eradicating the disease. Leprosy eradication teams visit communities; they move from door to door and offer their services in identifying leprosy and other diseases such as tuberculosis, filariasis and malaria.

Much of the rapid success of Kerala’s HOM program may be attributed to the state’s high literacy level. About 90 percent of the population – about double that of the rest of India – can read and write, thanks in part to the remarkable network of Catholic schools in Kerala.

As a result, HOM beneficiaries may obtain additional health information from local newspapers and health publications such as Health for One Millions monthly bulletin. Health prevention information, therefore, is more effective than in illiterate communities.

Population density is very high in crowded Kerala, as is unemployment. Unfortunately, the status of adult health and nutrition is lower than in several other regions of the country.

Health for One Million hopes to expand into the new millennium. The program will have to do so, however, without the care and concern of its founder, Mar Ephraem, who died suddenly in the spring of 1997 one month after his election as the first Syro-Malankara Catholic Bishop of Marthandom. Nevertheless, the Bishop’s goal to bring health care to the masses continues under the direction of Sister Eymard and her remarkable group of committed organizers and volunteers.

Sean Sprague, a California-based photojournalist, travels frequently throughout “our world.”