Chronicles from Central India: An atlas of rural health

Chronicles from Central India: An atlas of rural health. Yogesh Jain. Jan Swasthya Sahyog, Bilaspur, 2016. 318pp, ₹300.

‘Little do town-dwellers know how the semi-starved masses of India are slowly sinking to lifelessness…. No sophistry, no jugglery in figures, can explain away the evidence that the skeletons in many villages present to the naked eye. I have no doubt whatsoever that. the town- dweller of India will have to answer, if there is a god above, for this crime against humanity, which is perhaps unequalled in history.’

Statement made by Gandhiji at the historic trial, on charges under Section 124A of the Indian Penal Code, held on Saturday, 18 March 1922, before Mr C.N. Broomfield, ICS, District and Sessions Judge, Ahmedabad.

This could well have formed the preface to this book.

Readers of this Journal will have been moved by accounts of extreme poverty and its consequences on the lives and health of villagers and tribals around Ganiyari. On pages 228–9 of Volume 27 of this Journal, the first Letter from Ganiyari made its appearance.¹ With characteristic understatement, the author(s), who remain unnamed, introduced the village thus: ‘Ganiyari is a village in Chhattisgarh–nothing special, just another village in Central India.’ This Letter and those succeeding it have acquainted us with the tragedies consequent to poverty, powerlessness and brutal exploitation. The first Letter introduced us to some of these—unchecked infections, widespread malnutrition, marginalization of certain groups and poor health systems.

Those of us fortunate enough to live in relative comfort in cities will not recognize the extent of suffering, helplessness and indignity plaguing residents of villages and hills that surround Ganiyari unless we have the opportunity of working in hospitals such as the All India Institute of Medical Sciences in New Delhi (AIIMS) or King Edward VII Memorial Hospital in Mumbai, to which the poorest of our citizens travel long

distances—at times hundreds of kilometres—to seek relief and cure. Some, among us, such as Drs Shilpa and Shekhar Bhojraj, have gone the extra mile and travel repeatedly to and fro at personal expense to offer their specialized services at community health centres in remote villages.

Indeed, experiences at AIIMS stirred an extraordinary group of postgraduate doctors to do something to change the lives of villagers deprived of the amenities city-dwellers take for granted. On their website, www.jssbilaspur.org/history, they describe their decision to ‘develop an effective, low-cost, high-quality, community-based healthcare system that would be readily accessible to the rural poor and a model for the delivery of care in low-resource settings.’ Drs Saibal Jana, Surabhi Sharma, Rachana and Yogesh Jain, Anju and Raman Kataria, Anurag Bhargava, Biswaroop Chatterjee and Rajnish Juneja founded Jan Swasthya Sahyog (JSS) in the year 1996.

In doing so, they have joined others who set about similar tasks in various parts of India such as—Dr Ida Scudder and her acolytes in Vellore, generations of the Amte family, Drs Mabelle and Raj Arole, Drs Rani and Abhay Bang to name some.

The goals set for JSS were very clear: ‘From the beginning, we were committed to serving the poorest and most vulnerable patients—those who would otherwise lack access to affordable and quality care. In this spirit, we employed two main criteria while selecting an area in which to base our organization. The first was that we would serve in an area that was classified as backward by the government. The second was that we establish ourselves in an area with some history of a people's movement, or with active groups with a similar analysis and perspective. With our strong belief that health is directly tied to one's political and economic situation, we vowed that we would work not only to treat the biological needs of our patients, but also to ensure the social rights of the people we cared for.’

In 1999, a lease was signed with the Government of Madhya Pradesh for the use of the land and the buildings of the dilapidated irrigation colony in Ganiyari village. Their website provides details on the wonders they have worked there. I found it salutary that the complete list of ‘employees’ provided on the website includes the names of the founders of this collective under ‘Clinical Services’. The departments are listed alphabetically and the number of employees are provided (in parentheses): Agriculture unit (10), Ayurveda (2), Community Health programme (41), Clinical services (19), Driving unit (5), Guard (6), Kitchen (11), Laboratory (15), Medical Records unit (8), Nursing unit (39) and Sanitation orderlies (8). There are also 12 phulwaris.

The book under review gives us some details of their experiences in their rural health programme catering to over 2500 villages in Bilaspur, northwest Chhattisgarh. The narratives document not only the plight of villagers and tribals and their illnesses but also the roots of their diseases–biomedical, social, economic and cultural. The subtitle ‘atlas’ indicates the many photographs, charts and maps used to bring alive facts and figures.

The stories of 27 patients are narrated in considerable detail; 40 ‘picture stories’ carry short annotations. The spectrum is wide. The very first description of why Aghani Bai's son Dal Singh died from snake bite poisoning and the further impoverishment of the already hard-up bereaved mother sets the stage for what is to follow. Each narrative has, at its end, an analysis of why the tragedy described was inevitable, given the circumstances and steps needed to prevent recurrences. Many carry medical notes for the benefit of others working in the field, away from medical centres.

Malnutrition, rabies, malaria, eclampsia, postpartum haemorrhage, vesicovaginal fistula, tuberculosis of the spine and in children, epilepsy, HIV infections and addictions are some of the other personal narratives included here.

The village where Dashrath, the boy with epilepsy who burnt his legs as he fell into a fire during a fit, resembles almost all the other villages referred to in this book. ‘Mangalpur is a remote hamlet of 28 families and 150 individuals. Most single-family dwellings had just one room; a few had tiled roofs; all huts were made of mud with dirt floors. None had latrines or running water. The primary school, too, was housed in a tiny one-room building adjacent to a newer one that was never finished…. The electrical connection to the lone bulb inside the hut had been out of order for months. The head of the panchayat… demanded Rs 100 to get the responsible government official, based at the block headquarters in Kota to fix it. Jhum Bai could not pay. Hence it remained a useless relic. The battery of a torch lying on top of sacks … had expired long ago. … The roof leaked badly..The bore well, the only source of drinking water near their home had been out of order for a month. Two weeks earlier, each villager had paid Rs 10 to the panchayat to get the bore well repaired but nothing had been done.’

The picture stories (pp. 151–200) include patients with gas gangrene, wasting from tuberculosis, nerve abscess, tetany in a lactating mother, rhinosporidiosis and attempted suicide. The plight of the 16-year-old boy is particularly moving. The urinary catheter inserted when he suffered a pelvic fracture could not be changed as the family had no money to take him to a doctor. When they did manage to do so, the urethra was severely scarred. An entirely avoidable operation–excision of the diseased urethra and repair—now became necessary. Some stories in this section show innovations implemented by the collective to ease the lot of patients (p. 199 shows an example).

Many will find the maps of inequity useful in understanding the distribution of diseases in India and why some are dominant in the rural and tribal regions. The imaginative use of the software Scapetoad has enabled the collective to highlight parts of our country especially vulnerable to diseases of poverty.

I found it praiseworthy that despite the many difficulties the collective must have had in putting together the factual accounts, photographs, charts and maps, they were able to include inspiring poems and a list of books and films on the subject. Make sure you do not miss the poem entitled The nobodies on the rear cover of the book.

The JSS collective prefers anonymity when it comes to taking credit. Their End note acknowledges the help given both in their work and in the preparation of this volume. The prime movers remain anonymous. The only exceptions are encountered in the Blogs (pp. 202–30) and in the essays under Articles (pp. 232–58).

Thought-provoking quotations from the works of eminent scientists such as Rudolf Virchow, Louis Pasteur and Hans Zinsser are placed strategically. The collective has placed an index at the end of the volume.

Tata Trusts provided support to the group in their work and helped in the production of this volume.

The collective does not intend to rest on its laurels with the emergence of this book. They promise us more—a second volume with further personal accounts and an online edition with videos to supplement the text and pictures. (They have provided several photographs and seven video recordings of life and work at the collective on their website.)

This book has been in the making over the past 9 years. It deserves to be read not only by others working in similar circumstances to learn what can be achieved by sincere, hard work but also by those fortunate to live affluent and comfortable lives. How can we help such endeavours?