In the Bonesetter's Waiting Room

by Aarathi Prasad

  7

  The Mother Goddess

  THE GADCHIROLI DISTRICT in Maharashtra State was a ten-hour journey from Hyderabad, the last leg of which was a long, spectacular drive over immense dried river beds awaiting the monsoon rains and along small roads flanked by beautiful, seemingly peaceful forests of teak, bamboo and intertwining vegetation. It wasn’t just the distance or terrain that made Gadchiroli difficult to access. When I told my Hyderabad family where I was headed, they asked me whether I realised that I was going into a terrorist stronghold. The lush forests which are home to Maharashtra’s Gond tribes also offer ample cover to the Naxalites, an infamous Maoist group of guerrillas – and are well known as the location of their power struggle with the Indian police and military forces.

  As we passed through, the scenery along the road was serene, if at times desolate before the rains; shrubs and trees grew out of the vast, burnt red earth while emaciated cattle made their way through rice paddy past small groups of women in yellow, blue, purple and green fabric that billowed as they walked into the distance, straight-backed, water pots balanced elegantly on their heads. But signs of conflict were not invisible. In a small, very ordinary-looking village, we drove past the camp of a paramilitary battalion. Guarding its tall white turrets was a beautiful young woman, dressed in khaki, rifle aimed in readiness.

  As the one small main road became enveloped by the forest, now not far from our destination, my taxi began to slow. Two large buses had stopped, one on either side, and as we passed them thirty or so men ran silently and urgently out of the trees and towards the parked vehicles, firearms in hand and faces unmistakably determined. ‘They’re plain clothes police,’ my driver said, seemingly unfazed. ‘They must have heard about a Naxalite sighting here.’ He drove calmly on. I was rattled, and very relieved when we finally reached our destination among the trees, too late and too exhausted to do anything but sleep.

  Despite the local upheaval, the place I was visiting couldn’t have been more peaceful. Set up in the late 1980s to bring medical care to women who had none, SEARCH (the Society for Education, Action and Research in Community Health) was a hospital camp cum research centre, the brainchild of an energetic sixty-four-year-old gynaecologist/physician couple, Dr Rani Bang and her husband Abhay. I was there to observe their work on women’s and infant health. At breakfast in the mess, I chatted with some of the doctors, computer scientists and postgraduate students who were working there. The society’s catchment area included the general rural population as well as members of the Gond tribe – the largest tribe in this part of the country – which numbered ten million people spread across the jungles from central India towards its eastern coast. Its medical staff provide much-needed healthcare while its scientists gather and rigorously analyse data about public health and disease, working to create programmes best suited to tribal and rural lifestyles and medical needs.

  The camp’s new dentist, a bubbly young woman from Nagpur (the nearest major city, a four-hour drive away), told me they’d been trying to fill her post for a year. I told her it must have been challenging to attract staff to such a remote location. She laughed. ‘Well, it’s not just that it’s remote,’ she said, as others on the breakfast table nodded knowingly. As they went back to their offices and clinics, I was starting to get the picture too. The hazards faced by the medical staff are severe: if you Google Gadchiroli, details of the long-running, brutal low-level war with the Indian state fill the search pages: police gunned down or killed in bombings or by land mines; images of blood-soaked or dismembered bodies of those who had crossed or opposed the Naxalites.

  When I met Dr Abhay in the camp’s office, I admitted that I was largely ignorant about the Naxal issue. Abhay, a physician and public health expert, had been brought up in the same state, in a peaceful Ghandian community in Wardha, before spending the last nineteen years of his life living and working in a war-torn forest. I asked him about the dangers he and his staff face.

  ‘We haven’t had any encounters with them directly,’ he explained, ‘but they undoubtedly have a presence. To begin with, the Naxalites were supporting the ideal of egalitarian society, and revolting against unjust landlords. When they came, they were very motivated, they understood what Marxism was, what revolution was, though they were not very clear how they would bring this about.’

  From what I had read, this communist guerrilla group now seemed to make things happen through intimidation, threats, abductions, beatings, torture and summary executions – all in the course of a so-called popular ‘people’s war’. They had indeed, as Abhay indicated, emerged from a 1967 peasant uprising against the forcible seizure of land and confiscation of food grains (in the West Bengal village of Naxalbari – which gave them their name). Over the years, many of central India’s tribal people in Gadchiroli have become Naxal guerrillas – a response to their marginalisation by a government that has denied them rights to the produce of their traditional lands and threatened both their livelihoods and their way of life with dams, irrigation projects, mining or forest clearance.

  Nearly fifty years later, in the current ‘revolution’, their influence is largely felt through careful selection of their victims: village leaders and other persons of high standing, and those who either refuse to cooperate with them or are suspected of being police informers. The Naxals chase the police and the police chase the Naxals – and both are brutal. In the ongoing cycle of despair and violence, the ordinary lives of civilians are too often collateral damage.

  ‘Today they definitely cause enormous stress to people,’ Abhay continued. ‘Locals used to say we live under two governments. During the daytime, it is the Bombay sarkar (state government); and during night-time, it is the jungle sarkar – which means Naxalites. They do not move during the daytime very openly. At night-time they come to a village and ask for money, food, shelter, these young boys or girls.’

  Revenge killings are intentionally demonstrative, brutal, public acts of terrorism. ‘Sometimes they ask even family members to witness it,’ Abhay said. ‘Because of the Naxalites and the fear they cause, it is difficult to get our people to go to tribal villages. It’s risky also, but we do not have any security. No security will work against them. Plus it is not our philosophy to use arms. But we really have two kinds of security. One is that being part of the medical profession itself offers some protection. And secondly, when Naxalites say to villagers things like, “We should stop these SEARCH people, they might be American agents,” then the villagers tell them, “But then who will provide us with medical care? We want them to stay.” And usually they are not really pressed after this. We get a little trouble sometimes, but nothing serious.’

  Rani and Abhay might be impressively relaxed about the presence of the Naxalites and ongoing police battles between the two, but there are other aspects of life in Gadchiroli that they find much more serious. When they came here – in fact, the very reason they came here – there was a gaping lack of healthcare. Its rural people, and particularly its tribal women, had been living completely under the radar of India’s medical system.

  ‘In India the doctor to patient ratio is one doctor to two thousand population,’ Abhay told me. ‘The World Health Organisation norm is one doctor to one thousand population. So I wouldn’t say we are very bad, but there is an enormous concentration of doctors in our cities and in the private sector. I don’t know the number off-hand but in India, in rural areas, the ratio is nearer one doctor per ten thousand people. So there’s a lack of manpower, there’s a lack of supplies and medicines; the governance is poor. Usually when I discuss with the politicians they say there is no point putting in more money because our system cannot convert it into effective services.’

  Talking to Abhay gave me a fascinating insight into rural medicine in India. In a place where good medical care was almost entirely absent, the power of access to doctors was incontestable. In a sense, medicine triumphed where firearms had failed – SEARCH was off limits to terrorist attack
because, for the rural people and tribals alike, it was the best healthcare offering in town. But Abhay’s description of the political inertia was disheartening. It reminded me of what had motivated Devi Shetty to set up Narayana Healthcare. There had been criticisms levelled at Shetty for working outside the system, but from what Abhay was saying, the system was broken. On average, countries spend around six per cent of gross domestic product (GDP) on health provision. In India’s 2014–15 budget, the percentage of its GDP invested in healthcare actually dropped, from 1.2 per cent to one per cent, despite already being one of the lowest in the world (the average spend in developing countries is 2.8 per cent).

  Doctors and politicians alike seemed to be raising the same concerns – even if they increased the amount of spend, would it really deliver medicines and care to the people it was intended for? The government’s solution is still far from evident but, like Shetty, the Bangs’ solution was to do something themselves by identifying an area of greatest need and then trying to address it.

  Building links and gaining trust in the Gadchiroli jungle, however, would not be a simple matter of superimposing an urban medical perspective on their rural patients. As outsiders, especially when working with tribal people, trust would play a key role in the relationships between SEARCH staff and the locals. Fostering such trust would require a deep understanding of what rural life was like, the problems that really afflicted the communities, and getting to grips with superstitions and existing ideas about health and disease. And because there was no hospital in the place the Bangs decided to work, healthcare would have to start in the community, not in the clinic.

  As Rani told me, even as students both she and her husband had been keen to specialise in community medicine. At the start of their careers, when they worked in another, better served part of Maharashtra (Wardha, around 200 kilometres away), they realised their training had prepared them only for a clinical setting. But they found that conditions in a hospital and conditions in the community were very different. As Rani said, ‘In a clinic, as a doctor, I am in a powerful position. Patients come to me. When I talk to the patients, they have to listen to me whatever I say. But when I talk about community health problems, then the people have the upper hand.’

  Improving the health of communities is a complex business – probably particularly so in close-knit communities, where social structures and tribal or family bonds are incredibly important. In the Gadchiroli communities, long excluded from adequate external healthcare provision, people had their own approaches to maintaining health and ameliorating disease; and health advice was passed through faith healers, mothers-in-law and other family or wider group members. The diseases people were contracting and dying from were not well documented by such communities, so the Bangs decided to make their own enquiries. First, though, they had to learn some appropriate epidemiological techniques and research methodologies. In doing so, they noticed that almost all the research into India’s health problems had been done by non-Indians. ‘So we thought, why can’t we do the research?’ said Rani. ‘Here we were already close to our community.’

  As she spoke, villagers from the remote jungles of the Gadchiroli district were filing into the jungle camp’s consulting rooms, which had been built using money given by her father and from charitable donations. For the local people, the hospital she and Abhay had set up and run, the mobile health buses and the village health workers they trained had brought unprecedented access to high-quality healthcare, particularly for the women in the area.

  It was one of their early, female-focused studies, which had been done in this hospital camp, that I had partly come to see Rani about. A few months previously I had attended a global health conference in London, and been shocked by the images and statistics that were presented on maternal mortality in India. In this country where goddesses were revered, it seemed its mortal women were being sidelined in a way that had raised a red flag among health organisations, governments and NGOs worldwide. The camp’s study focused on the health of mothers and newborns, and it involved the recruiting and meticulous training of nurses, midwives and community health workers, to dramatic effect.

  Rani described to me how in tribal areas maternal health was worse than in other parts of India, something that had inspired her to conduct a study whose major focus was on women’s and children’s health. She said that, until that point, women’s health was looked at only within the context of their role as mothers. This included care during pregnancy, delivery and post-partum, and family planning but excluded sexual health education, easily accessible and safe abortion services and treatment for reproductive tract infections (RTIs) and sexually transmitted diseases (STDs). Rani wanted gynaecology and sexual care to be a part of basic healthcare for these women. ‘So we started with a study on women’s reproductive health,’ she told me.

  Ninety-three per cent of Gadchiroli’s million inhabitants live outside the area’s urban settlements, and more than thirty per cent of them belong to the Gond tribe. The Gonds are technically divided into three types – the Maadiya Gond, who live in the hills, and are said to be the least changed by the trappings of modern life; the plaindwelling Gonds; and the Raj Gond, so called because they are said to be the descendants of the old kings of the tribal area. Such old divisions seem to have blended latterly, and though many now dress and live in ways that are indistinguishable from the general Gadchiroli population, tribal villages still run under Gond traditions. There, food is mainly hunted or gathered and, unlike the more modest, full-length dress of other rural Indian women, many Gond ladies wear their saris short and without blouses, and their bodies are decorated with tattoos.

  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 emphasi
s 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.