In the Bonesetter's Waiting Room (22 page)

The years of isolation and the lack of access to health services in these forest villages had lent credibility to the magic of faith healers and the rumours of witchcraft. It wasn't just the remoteness, the snake- and malaria-infested jungle or the terrorists that made access to healthcare more difficult for tribal people, or the fact that in general doctors do not want to go there. There was also a double dilemma – not only was there a lack of facilities, but Gond culture did not encourage them to seek early medical care, because they have their own spiritual healers, their belief systems and their (sometimes lethally dangerous) superstitions. Most of the vaidus to whom tribal people turn employ mantras, tantras, magic – and spiritual healing. Rani had told me that although occasionally they also use some herbs, those are secondary to the spiritual healing. That spiritual mystique was what gave them power over the minds, and bodies, of their people.

Rani's work had also unearthed some extremely distressing stories resulting from the influence of the vaidu and traditional beliefs of the tribals. Some of the rural people liken acidity in the stomach to a growling cat, leading to the logic that since cats are afraid of fire, branding the stomach with a hot iron will drive the problem away.

Until recently, it had also been traditional to bury a baby when its mother died, since there was no system of adoption and therefore no one to take responsibility for the child. Rani had also been told of the sacrifice of a six-year-old boy. His mother was a traditional midwife whom Rani had herself trained. Despite the mother's protests, the village community, including his father, slit the child's throat, soaked nails in his blood and sold them to people who put them into their paddy fields to increase their yield.

Through SEARCH, Rani had been able to prevent other human sacrifices, such as of a man alleged to have used black magic to make a neighbour ill. But many slipped through the net. Though Gond girls have a degree of autonomy before marriage (choosing their husbands and receiving a bride-price, the opposite of the dowry system in wider India), tribal society could at times be surprisingly brutal to women, especially those who were outspoken. In one horrific case, a woman was declared a witch and held responsible for the constant illness of a relative's daughter. She was hit in the stomach with a stick and with shoes, had her clothes torn off and was forced to drink another woman's menstrual blood. Her daughter was convinced that her mother would certainly have been killed, had she not been there to plead for her.

Throughout our conversations, Rani and Abhay always emphasised that the challenges to the health of India's women were far, far broader than simply the danger of dying in childbirth – something the outside world focuses on to an almost obsessive extent. The women of Gadchiroli, for example, were at risk for multiple reasons: poor nutrition, poverty, their husbands' violence and alcoholism and the harmful interventions of spiritual healers, apart from the lack of trained medical professionals and adequate health facilities.

I had realised by this point in my travels that public hospitals in India were in the main badly resourced in terms of funding, equipment and trained staff, and that there were huge variations in quality of care depending on what state you happened to live in, and whether you lived in the city or the countryside. The Millennium Development Goals India signed up to in 1990 of bringing down child mortality by two-thirds, achieving universal access to reproductive health and, by 2015, reducing maternal mortality by seventy-five per cent have yet to be achieved.

SEARCH had found a way to commission rigorous studies in difficult environments, gather evidence, make best use of existing resources and provide robust ongoing training for local people who now served as effective and efficient health workers. They had also collaborated with NGOs in other parts of Maharashtra to replicate their Gadchiroli methods, and there, too, have helped to cut newborn deaths by fifty per cent, a success rate that other tested methods such as micro-nutrient fortifications for malnourished children have been unable to match. Their work has been commended by
The Lancet
, the WHO and Unicef, among others, so I was curious to know how far the government of India had taken the Bangs' findings on board, or what broader improvements were happening in order to achieve its goals, especially in terms of the widely reported scourge of maternal deaths in India.

‘We have also studied mother's deaths,' Abhay told me. ‘You might consider this heretical, but the fact is that maternal death is a very rare event.' I knew that the Millennium Development Goal target for maternal deaths was 103 for every 100,000 births. Surely India's rates were far higher than that? ‘Today the maternal mortality rate in India is 178,' Abhay continued, ‘which means, out of one thousand deliveries, there are under two maternal deaths. So if you ask village women, they are not much going to talk about maternal death: they are more likely to talk about difficulties or complications during labour … It's not noticeable – for them, snake bite is more dangerous.'

Abhay's point was that, while maternal health is, of course, a major issue, looking at the numbers alone did not make sense in places like Gadchiroli, where there were far greater and more common problems than death in childbirth per se. Addressing the risk factors that can lead to such deaths would surely be a wiser strategy. ‘It's looking after women before the birth, during the birth and after the birth. Monitoring is very important during pregnancy,' Abhay said.

But government policy in India continues to focus on the birth itself – or, more specifically, where it should take place. There has recently been a drive to get women to give birth in hospitals or clinics, away from their homes and families, a reversal of a failed initiative begun in the 1980s that had promoted the use of traditional
dais
(community-based midwives).

‘The
dais
received initial training,' Rani said, ‘but never ever any retraining. It was only an effort on paper. Their kits were not replaced, they were not given any medicines, any equipment, nothing. And in spite of that, the
dais
were working.'

The government had promised they would be paid, but many never received a single rupee, according to Rani. The women they assisted also stopped paying for their services, since the
dais
were now supposed to be earning a state wage. ‘So they had no income,' explained Rani.

I recalled how official reports of the ASHA programme cited as reasons for its success exactly the points that had been overlooked with
dais
– regular meetings, replenishing of supplies, timely payment. Because of these miscalculations or misdemeanours, the officially backed
dai
system died a death and, worse, a traditional practice that might have functioned as well as SEARCH's
arogya doots
, began to be blamed by medical communities for a high level of maternal mortality. My own research supported what Rani told me: when I had mentioned
dais
to gynaecologists in an urban Bangalore hospital a few months earlier, I had been told that they were unhygienic in their practice and untrainable.

In 2005 the government's
dai
strategy was replaced by a programme known as Janani Suraksha Yojna or JSY (‘the Protection of Mothers Project'). The initiative was created under the National Rural Health Mission to reduce maternal and newborn deaths by promoting institutional delivery among poor (rural) pregnant women. Participants were offered a variable cash incentive (around Rs1,500), to help cover the cost of travel and neonatal supplies.

This was fine in theory, but there were serious practical problems, not least the fact that many rural women have no proper hospital they can go to, just a local public health centre or subcentre. ‘There are often no doctors in those places,' Rani said, ‘and the nurses don't always know how to manage the complications. They don't know even how to give stitches, if there is a tear during the delivery. Things are so bad.'

The second point concerned the cash incentives. In 2014 eleven young women in rural Chhattisgarh died after taking part in a mass sterilisation campaign they had been paid Rs1,400 (£14) by the government to participate in. A careless attitude by staff towards incentivised patients was blamed, and the point was also made that, when women who are living in poverty are offered money to undergo a procedure, they are likely to accept whether they want to or not. Photographic evidence of the sterilisation victims made it hard to disagree. These were very poor women who might easily have made other contraceptive choices. As mothers lay dying, their children sat helplessly next to them on the hospital beds, while other relatives sat close by on the floors of those sparsely equipped wards.

Sadly, this was no isolated incident. Over the years, thousands of women have died following unnecessary admission to ill-equipped institutions with under-trained or negligent staff. The issue was further complicated by corruption. Rani described to me how many women who took up JSY's offer either received no money, or, on the other hand, spent it on things for which it wasn't intended. Payment was made only to those holding a BPL (Below Poverty Line) card, but, as Rani explained, ‘Actually we see government employees with BPL cards and the real poor – the people who should have that money – they don't get one. And those who do get paid – that money is supposed to buy food and medicines for the mother and the child, but gets spent on household items. Furniture and other things like that. And so the total purpose is lost.'

The combination of forcing women into hospital and giving them cash incentives also seemed to be having another unwanted side effect: a rise in unnecessary caesarean operations. Abhay thought this could be due to the more intensive monitoring of hospitalised women during labour. ‘There may be several false alarms, and doctors get panicked.'

He also believed that some women were undergoing procedures needlessly for altogether more sinister reasons. Some obstetricians or doctors, aware that their patient will soon be in receipt of a JSY payment, will tell the family that their relative requires an entirely unnecessary caesarean. ‘They say, “This woman is in danger, and an emergency operation must be done. If you pay me three thousand rupees, I can help you.” Of course, every woman in labour looks to the family like she's seriously ill, so they pay up, even though state hospitals are supposed to provide free care. Some of our own workers have been victims, even though SEARCH is quite a well-known organisation – such payment is still so common that they don't care.'

I wondered whether Abhay had been overstating the problem but, as I was later shocked to discover, what he had told me was no isolated series of incidents.

More than 800 million Indians have little or no access to modern healthcare, and statistics for 2013 show that there were seventy-two suicides daily by those with illness for which they could not afford to seek help. Some part of the blame must fall at the door of the corruption rife in many state-run hospitals. Sinking into a deep depression over the basic human right of access to healthcare begins to make sense once you realise what an ordinary person – even a pregnant woman – must face. There are innumerable news stories about the desperate facilities and underhand dealings women in labour often navigate: disturbing pictures of rooms full of women on bare metal beds, the ward floor strewn with blood-stained cotton and miscellaneous rubbish, loose wires dangling lethally from the walls. There were stories of payment demanded not only for caesarean sections, as Abhay had said, but also for drugs and bandages, food, gloves, blood tests, examinations – charges were even levied in order for the woman to receive stitches
after
she'd been cut, or to receive the government benefits she was owed. One couple was asked to shell out Rs500 as the going rate for having had a son delivered, and another woman was charged Rs750 (three weeks' salary) but died in labour, leaving behind three young children.

Government statistics reveal that, today, nearly eighty per cent of Indian childbirth occurs in hospitals. But, for a programme that has heavily invested public finances over the space of a decade, the pace of improvement has been decidedly leisurely. From 500 deaths per 100,000 women in 1996, to 212 in 2009, to 178 in 2015 – the trajectory of falling maternal mortality is showing a frustratingly steady rather than reassuringly steep decline. Certainly, through JSY there has been no rise in maternal deaths, but that might be due to a number of factors, buffered by the improved economic status, nutrition, education and progressive urbanisation of some rural communities.

Even if women don't end up on the receiving end of surgical extortion, there are still disadvantages to giving birth in hospital. Hospitalisation is not universally recommended even in Western healthcare systems – the model for this programme. Abhay reminded me of the UK's National Institute for Health and Care Excellence (NICE) guideline that moving women who have no other risk factors during pregnancy to a hospital for delivery puts them at an unnecessary risk of suffering various hospital-based complications – caesarean section, panic, hospital infections. It was a sound argument. In India, the low-risk BPL women JSY was supposed to protect could well be far better off at home. ‘The advantage of moving to a hospital, if any,' Abhay said, ‘[is that] there is a facility for blood transfusion and a caesarean section. [But] the WHO says that only around ten per cent of women need an intervention. So for that ten per cent we are moving one hundred per cent of the women.'

‘What about the big dangers, like obstructed labour or eclampsia, that can occur suddenly?' I asked.

Abhay agreed that, ideally, wherever a woman might deliver, she should have access to emergency obstetric care within two hours. This, though, was a concept very different from moving every woman to a hospital for delivery. A far more practical and, in all likelihood, hygienic proposal would be to allow a woman to deliver anywhere, but to ensure that emergency transport, and timely access to a hospital, are on hand.