In the Bonesetter's Waiting Room (21 page)

While no one in rural Gadchiroli would be considered well off by urban, middle-class standards, rural villages in which Gadchiroli's majority (non-tribal) population live have concrete or brick-built houses, a few vehicles, schools and other infrastructure recognisable from any small town in India. The tribal villages are striking by contrast. They emerge like mirages from the forest, in a clearing but never far from the trees, because the jungle provides tribals with food, bamboo and other essentials. The village itself consists of twenty or fewer thatched, one-storey mud-brick houses, open communal spaces and a few shared, free-running livestock.

There is no money to speak of here – certainly no disposable income. Food and services are shared within and among villages. Tiny incomes are generated from forest resources, more so since a recent Government of India Forest Department decision to allow tribals to benefit from the natural produce of their traditional lands. But these villages are
very
remote, which means that as well as being poorer than their non-tribal neighbours, tribal women are often less well nourished (an effect exacerbated by restrictions on what pregnant Gond women are allowed to eat) and very, very far from hospitals should an emergency arise.

Rani's early studies found that nearly fifty per cent of the women they studied had an RTI. Interestingly, these RTIs were due not just to AIDS or sexually transmitted diseases, but also to poor nutrition. General malnutrition, and conditions such as intestinal parasites and dysentery that prevented the villagers absorbing nutrients from what they did eat were rife, as was the lack of dietary vitamins important to reproductive health. Diet-related and genetically transmitted anaemia was rampant, and there were also other infections introduced during homespun surgery or giving birth in septic conditions. Even though abortions had been legal in India since 1972, unlicensed abortions persisted owing to a dearth of appropriately qualified medical staff, resulting in some truly horrific infections.

There were also mental health issues and domestic abuse. Women often saw alcoholism among their men as the most troubling of their problems. Drunken husbands brought home STDs and the beatings they gave their wives sometimes ended in a miscarriage. Rani soon realised there was much more to women's reproductive health than pregnancy and childbirth. The data she gathered made a significant policy impact across the globe, so much so that now a similar emphasis on reproductive health has been accepted all over the world.

In order to provide the kind of wide-reaching care that would be able to treat and document as many reproductive health problems as possible and, importantly, generate an environment of trust in which rural and tribal women would feel at ease to discuss these issues, SEARCH trained local men and women to be health workers. The programme has been a success: in 2005, when the Ministry of Health's National Rural Health Mission began their Accredited Social Health Activist (ASHA) programme, it quickly took up Rani and Abhay's system of home-based care for newborns. The acronym ASHA also spells the Hindi word for ‘hope', and it involved training one sufficiently literate person (nowadays generally a woman) per village in India's rural areas in basic medical skills, allowing them to provide primary, as well as some more complex, care to the community.

In the ministry-led, publicly funded scheme, there are currently 900,000 ASHAs across India. All of these women fill an unmet need, and the government officially recognises that critical to their success are replenishment of their medical supplies, their timely payment, regular support meetings, provision of transport for them and links to their nearest functional health facility. Unfortunately, the first three points seem not to be universally implemented, and pose a challenge for these women to continue their services. In Gadchiroli, where the operations are managed closely by the Bangs and their colleagues and cover a much more manageable geographic area – the ASHA system, which they now call
arogya doot
(health bringer) is an effective and efficient one. More than thirty intakes of these workers have now graduated from the Gadchiroli training programme.

One of the first interventions they implemented was home-based newborn care. At that time, many babies were dying from preventable deaths: young mothers in rural households either did not know how or did not have the resources to prevent them. When Rani and Abhay started, out of every thousand live births, 120 were dying before they reached the age of twelve months. They discovered that the main cause of this was pneumonia, and there was no healthcare available in rural areas for what they knew was a treatable condition. Through a combination of intervention by trained health workers and an improved immunisation programme, the infant mortality rate dropped by a third.

That was good, but for the Bangs, not good enough. ‘It was not going down any more,' Abhay told me, ‘so we again looked into that … we realised that sixty per cent of the deaths were happening in the first month.' Despite the lack of specialist facilities such as neonatal care units and incubators, Rani and Abhay gradually managed to force down newborn mortality from eighty per thousand to twenty-five. He showed me one of the innovations he had introduced – an ingenious piece of equipment designed to help women with no education diagnose a lethal condition when no doctor was available. ‘This is sort of an antique piece now,' he said as he explained to me how it worked. It looked very much like a child's toy, part abacus, part sandtimer, with a row of ten beads, nine blue and one red.

‘So this is a one-minute sand timer, now this is for a newborn baby, and this is for an infant or toddler,' he said, pointing to one of the two rows of parallel beads along the ‘abacus' part of the wooden device.

‘According to the WHO guidelines, a baby up to the age of two months has got a respiratory rate which is sixty [breaths per minute] or more – for an infant or toddler, have a respiratory rate of fifty or more. Now our
dais
(traditional midwives) could count up to ten. So …'

He turned the ‘toy' upside down, and the sand started flowing downwards.

‘You count the child's respiratory movement – for every time the child's chest raises, that it takes ten breaths, we move one bead. Now if before the sand has passed – which means one minute has completed, if you have had to move the [last] red bead … it is pneumonia. I found that in eighty-two per cent of cases, the diagnosis matched. But this was twenty-seven years ago. Now we have selected one
arogya doot
in every village to become a community health worker, and she will be trained to use a wristwatch and actually count the child's respiration.'

The wristwatch was part of a health workers' kit carefully designed by Rani. Simple yet effective, it also included a thermometer, aspirator, scale, medicines, syringes, antibiotics, blankets and a warm sleeping bag.

I had learned that one of the traditional practices of tribal women was to leave babies naked for their first month. Until the baby's naming ceremony, a new mother and her baby would live in a small basic shelter, built for her outside the family home. The naming ceremony required a substantial outlay to provide food and alcohol for the entire village, consequently the mother and child could be left there for a long time. In cold weather, some of the newborns stood little chance.

In a nearby village I watched Anjana Uikey, the local tribal SEARCH health worker, as she skilfully demonstrated the procedures Rani's team had trained her in. Anjana's house was entered through a small courtyard garden filled with flowers. Petite, with jet-black hair, glasses and a pretty green sari, she offered me a chair in her main living space among a trolley of vegetables, kitchen utensils and rolled-up sleeping mats. As I sat, she rolled out a mat on the floor, piece by piece laying out the kit Rani had assembled. Anjana showed me how she used each item, wrapping a demonstration doll in a blanket; telling me how she would teach young mothers to use the sleeping bag and do the same. Her own children had been delivered at home, and since 1995 she had gone to SEARCH every three months for four days of refresher training, and to top up her supplies.

Anjana's meticulous work, and her conscientious way of thinking about what she did, were clear from our conversation. ‘I enjoy my job,' she told me. ‘People respect me now. When I see children playing around the village, I feel proud, because I helped them be born safely, I made sure they were not at risk of pneumonia and diseases.' And if they were at risk, Anjana also knew she had helped to avert what was now, for her and the mothers with whom she worked, preventable suffering.

In the following days I went to other tribal villages with the rural health mobile medical unit, travelling with Rishikesh Munshi, a young doctor from Nagpur. Along the way we talked about what it was like to work there, and the ailments he had commonly seen. Rishikesh's friends and family thought him crazy, leaving the city with a good medical degree to work in the terrorist-ridden jungle. ‘But I didn't want to sit behind a desk,' he told me. ‘I wanted to actually work closely with the people.' In his student postings in government hospitals he had seen at first hand the gross inadequacies of the infrastructure and the desperate lack of equipment, medicines and manpower. ‘The doctors only turned up for two hours in the morning,' Rishikesh said. ‘Instead of doing their afternoon shifts, they went to work at their private practices.' I asked him if they were being paid a full-time wage by the government. ‘Yes,' he said. ‘It is very unethical. But the nurses were wonderful. Everything I learned there I learned from them. Actually, I learned to do stitches from the ward boy. He was so used to there being no doctors available that he had taught himself.'

Though Rishikesh and the mobile unit were well resourced and staffed by trained and dedicated medical personnel, the patience and resourcefulness he had had to develop during his rotations must also have proved useful. He was wonderfully calm and jovial, even when our vehicle broke down on a narrow road in the thick of the jungle. As we sat on the edge of the forest in the forty-four-degree heat, he recounted more tales of conditions in rural hospitals.

When we finally reached our destination, the nurses and registration staff set out their log books and medicines under the veranda of one of the tribal village's twenty or so huts. This was a typical settlement of around 200 people, located in a clean and beautiful jungle clearing. In the distance, I could see a circular mud wall that had been raised up to demarcate it. A few goats, pigs and cows were amusing themselves; some small boys were doing the same.

‘The cows are like dogs here,' Rishikesh joked. ‘I've seen them jumping over fences and playing like pets. The tribals don't drink their milk because they say an animal's milk is for their babies. They only rarely eat their meat. They just keep them on the off chance that a bull might be produced for the rice paddies, I think.'

As our van played jolly film songs through its speaker to announce the medical team's arrival, the SEARCH-trained tribal community health worker set up a couple of day beds for patients to sit on. Several children and deliciously chubby babies arrived with their mothers – women with striking high-cheekboned faces and tattooed skin, wearing short saris. ‘A lot of the children have ringworm and scabies,' Rishikesh said. ‘Sometimes their hygiene is not good – we advise them on keeping clean as well as giving medications.'

As the nurses recorded the weight and blood pressure of each new arrival, Rishikesh carried out routine checks on newborns, examined children with various infections, elderly patients with hypertension and women with back and limb pain – the consequences of the hard labour they did in their homes and in the forests. Others had diarrhoea or pneumonia, tuberculosis, leprosy, STDs, intestinal worms, or hereditary sickle-cell anaemia – a consequence, ostensibly, of the historical prevalence of malaria in the region. The forest can be a dangerous place: people fracture bones falling from trees, mosquito bites are potentially lethal and snakes – cobras, vipers and kraits – are a constant terror once the monsoon rains begin.

But while the babies were well nourished, the women were not. ‘I've seen mothers who weighed thirty-five kilos give birth to normal weight babies,' Rishikesh said, prescribing yet another fifteen-day course of vitamins and iron to yet another anaemic mother.

Rani had also told me how ideas of pregnancy and birth influence tribal women and how she has had to allow for them. ‘Once,' she told me, ‘I asked a group of traditional midwives about stillbirths. Everyone denied ever seeing one. At first I thought they were trying to protect their reputations, but then I realised that their concept of delivery is different from ours. To them, the baby pulls itself out rather than being pushed, so all babies must be alive when they are born, even if they then die immediately. They also see large babies like obese adults – lazy – while lean babies are considered active. So they told me not to tell a woman to take iron or calcium to increase their babies' birthweight; tell her instead that it will make her a stronger mother. It is a different way of looking at birth.'

Getting women to talk about pregnancy and what ailed them was also still a work in progress. In the village, Rishikesh and I talked more as we watched the nurses at work.

‘Every worker should be trained to do everything here in case one day we don't have a member of the team,' he told me. ‘The nurses and midwives know how to properly register patients and dispense medicine. We want the nurses to be able to do more too. Most doctors here are men, but we saw that reports of gynaecological problems went up twelve times after our female nurses were trained to collect medical histories.'

I couldn't stop staring at a particularly beautiful baby who had a strangely symmetrical, dotted pattern on the top of its head. Our tribal colleague from SEARCH told me it could be the remnant of some herbal hair oil, but it looked too perfectly patterned. Rishikesh and I speculated that it could be a tattoo placed there as a talisman or intervention against pain or disease. ‘Once I saw a baby with thirty-seven burn marks on her stomach,' Rishikesh told me. ‘The baby had had a distended abdomen, so its parents took her to a vaidu [a spiritual healer] for treatment, and he burnt her with a hot iron.'