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 a
nd 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.’
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 stopp
ed 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.’
In the Bonesetter's Waiting Room Page 18