In rural Chhattisgarh, haunted by poverty and fragile healthcare, a 55-year-old man weighs only 28kg; an eight-year-old boy will die of rabies because his labourer parents work for twelve more days before seeking medical help; and doctors try hard to save a woman who has consumed pesticide
BY DILIP D’SOUZA
PHOTOGRAPHS BY TOM PIETRASIK
When I first see the woman, she is lying on a bed in a clean and spare room. She is unconscious, her head thrown back, her neck muscles straining. She has swallowed poison in an attempt to kill herself, and when we first enter this room where she lies bedraggled and insensate, Dr Yogesh Jain looks up and says he is sick of getting these cases.
This is the eighth or ninth one he remembers in recent months, he says andadds that she has less than a 10 per cent chance of survival.
It is a Thursday morning. She has anklets on, a string of small beads—red,white, blue—around her throat. The toenails on her right foot, but not the left, are painted bright red and one toe wears a large ring. She is wearing a crumpled mustard-yellow sari and blouse. Her blue petticoat is visible below the folds of the sari. Her long hair is disheveled around her head and that word alone reminds me, of all incongruous things, of Milton in “Paradise Lost”:
Shee as a vail down to the slender waist
Her unadorned golden tresses wore
We are at the Jan Swasthya Sahyog (JSS, “People’s Health Support Group”) in Ganiyari, in central Chhattisgarh. It was started in 1996 by a team of doctors who left comfortable jobs and a chance of a lucrative career at the All India Institute of Medical Sciences (AIIMS) because they wanted to work in rural India.
JSS now has 30 beds, two operating theatres, a fully-equipped lab and runs three outpatient (OPD) clinics every week. All this on a plot of land where, fifteen years ago, there were only a few abandoned sheds amid stands of tall weeds. In spite of the impressive achievements, the patient load remains overwhelming, always outstripping the rate at which they add facilities or the rate at which they can work. Success and a name for excellence and affordability mean they attract ever more patients from ever further away.
The JSS catchment area covers about 1,500 villages, with a population of about 800,000. The rush of patients on any given day at the Ganiyari hospital is not merely an indication of the quality of JSS’s healthcare, it is also a testament to the lack of anything comparable in the region.There is a government primary health centre (PHC) in Ganiyari itself, not far from JSS. But typical of PHCs the country over, it rarely has any doctors, let alone patients, and its appearance of dingy neglect hardly inspires confidence.
Over the years JSS has acquired a reputation that patients mention again and again as they wait, utterances starting always with “suna hai ki” (“I heard that”): “I heard that my illness would be cured here … the doctors are good here … medicines are available cheaper here … at least I will be seen here.” Thursday mornings are ordinarily reserved for JSS staff meetings, but the poisoning emergency has turned the hospital’s routine upside-down.
The room is hardly more than twice the size of the bed on which the woman is laid out. There are two doors near the head of her bed, across from each other. At the bed’s foot there are a couple of stands, like spindly, lanky sentries, to hold drips. On a small stand in a nearby corner is a heart monitor, a squat device with a bright digital display. A cable snakes from it, down onto the floor, across the room and up to her finger. Next to it is another bed, patient-less right now and hence used to stockpile tape, bandages, drips, instruments and other medical paraphernalia that the doctors will need. Three doctors and four nurses complete the inventory, all of them trying not to trip over the cable.
In this small room, with us in there as well, this is a crowd.
Dr Jain and his JSS colleagues are trying everything they know to save the woman. She is unconscious and immobile when I first see her, but the heart monitor tells us that she is alive—her pulse is 127.
Suddenly she groans and her head nods strangely as her body goes into a seizure. Under the sari, her legs tense and stiffen, and she shudders. As her body thrashes about, the nurses manage to give her an injection and get a saline drip started.
They want to attach a second drip, but she jerks so much that they give up. Standing beside her head, Dr Raman Kataria says, firmly and quietly, “Aspiration, suction!” All at the same time, the nurses struggle to get a tube into her mouth, put a tongue suppressor in place and fit a mask over her face. It is hard work, as her body continues to flail about and her jaw is locked firmly shut.
Dr Jain says, “She has bitten her tongue.” There’s a small basin near her face, positioned to catch her spittle. From the other end of the bed, it is hard to identify what is in it, but whatever it is, it’s turning a bright red.
She is still, for now.
Lying on the bed beside the basin are several surgical instruments laid out on a cloth and a sheet from a magazine with an oddly bug-eyed portrait of Bollywood beauty Kareena Kapoor.
The heart machine suddenly goes blank. My god, I think, her heart has stopped.
But it turns out to be a false alarm. With all the thrashing about, the sensor has fallen off her finger. Dr Jain picks the sensor off the floor and reattaches it. The monitor beeps, showing 126, then 124, 130. He has also been giving her oxygen, pumping it into her through a ventilator. A nurse now takes over the pumping from him. The ventilator looks like an oversize American football and sounds like a piston.
Dr Jain now sticks something into her blouse, then palpates her throat. The woman’s chest heaves. For the first time, I notice how small-made and slender she is. She cannot be more than 30 years old.
Dr Jain asks, “Is her husband here?” He asks again. Someone from the crowd replies: “Phone kar ke bulaiye hain.” (“They’ve phoned him”).
On the heart machine, her pulse has shot up to over 140.
Outside Nagore in Tamil Nadu, a few days after the 2004 tsunami, a large earthmover arrived to do a miserable job. First, it dug a gaping hole in the ground. That was done almost surgically, the implement rising and falling in quick slashes, dumping mud to the side. When the hole was ready, the earthmover turned almost gentle. There was a man operating its levers, of course, but the effect he had on that large claw was nearly magical. It turned thoughtful, contemplative. It hovered above a body impossibly tangled in fishing nets, as if trying to decide how to pick it up. The mechanical claw descended and almost did the job.
But no. What about the other way? It turned slightly, descended again. No, better go back to the first angle. In this fashion, the thing finally cradled the body, carefully, like a baby. Moved to the right and … the body slid off. The strands of the nets, themselves caught in a mess of bushes and pots and timber and assorted debris, pulled the body back. Not yet, they seemed to be saying. You died, but you don’t get buried that easily.
Watching helplessly that day, a question came to mind, over and over: Am I a voyeur for noticing the swell of a young breast on this sad form, the only sign that she once was a woman? Was Milton going through similar emotions when he wrote, a few lines later in the same verse from “Paradise Lost”:
Nor those mysterious parts were then conceald,
Then was not guiltie shame, dishonest shame
Of natures works, honor dishonorable…
Something like that happens in this room in Ganiyari. I feel like a voyeur, watching helplessly again as this slim woman hovers between life and death and this team of doctors and nurses tries desperately to ensure she goes one way and not the other, their hands and arms a blur of movement.
Yet when they have to touch her, they are careful and gentle, yes, nearly loving.
That day outside Nagore, the earthmover’s last affectionate gesture was when it picked up the girl, finally freed of nets, and lowered her into her freshly-dug grave. Done with that, it made a tight turn and sped—as much as an earthmover can speed—to the next body that needed extrication. Is it the same here at JSS? Emergency following fast on compassionately handled emergency? What would happen to the woman on this bed? Would she too soon need a grave?
A man outside leans in and tells Dr Kataria that her husband is on his way from the brick kiln where he works. The couple must have had an argument before he left home, that’s probably why she reacted this way, one of the nurses observes
The comment reminds Dr Jain of a 21-year-old whom they treated last week. He had swallowed the same stuff. The young man quarreled with his father, then ran out of the house and bought the chemical at a nearby store. Dr Jain mimics pouring it down his throat.
The pesticide is made from the chemical endosulfan, banned in over 60 countries but used widely in India under the brand name “Endoguard”.
Dr Jain says, “As a pesticide, it hardly adds to crop yields, but it kills so many young people. We find it hard to get supplies of the drugs we need, like morphine, but any child can buy this one.”
Dr Kataria speaks, quietly, bringing us all back to the present, “She’s starting another seizure, Yogesh.”
She’s thrashing again, feet thudding in a staccato rhythm against the bed. As we watch, the seizure gets steadily stronger–more wrenching, more frenetic. Her entire torso strains upward off her bed, pulling mightily against the nurses who are trying to keep her down. Her upper arms tense with this unconscious effort. Her muscles are visibly bulging as she fights the nurses’ grips. Who would have guessed she possessed brawn like this? I am reminded of Serena Williams hitting a backhand, those raised arms like overgrown Coke bottles, of the power in those swelling bionic biceps. In this frail body, signs today of that kind of strength.
Dr Kataria nearly whispers, “Thio, 250 ml.” The nurses try to inject thiopentone in her wrist, struggling to hold her arm steady as she shivers and shakes. One Draupadi, handles the syringe and simultaneously dictates to Dr Jain what they are administering. He writes it down on a pad, with carbon copies. When they are done, Dr Kataria asks for a dose of antibiotics, because there’s a risk she will get pneumonia.
Dr Jain looks up from his carbons to ask, “thiopentone kitna diya?” (“How much thiopentone did you give?”) Dr Kataria answers, “250 ke doses mein teen baar diyen.” (“250 ml doses, three times”).
Watching the struggle to inject her for a few seconds, he says, “Tape bada kato.” (“Cut a big piece of tape.”) He wants a port on her other wrist, so they can start a drip through there. The nurses switch the plastic drip bags regularly, punching holes in each new one with a syringe.
The heart machine’s sensor flies off her finger again, she is jerking so much. Dr Jain looks over at the nurse handling the ventilator, then observes to the room at large, but almost to himself, “Without effective ventilation, one hundred per cent she would have died by now.”
Villagers travel long distances to Ganiyari, even for just an OPD consultation. Since the Chhattisgarh government has shut down the state transport system, they must rely on private bus services. This means being subjected to the whims of private bus operators. Several patients spoke of services being suddenly withdrawn because the operator contracted to supply buses to a wedding, or a political gathering, or other lucrative ventures.
Riding on these buses, one patient with a foot injury journeyed to Ganiyari from Ambikapur, nearly 200 km away, though there is at least one large hospital in Ambikapur. “I heard that the doctors are good here”. What would a fever-stricken resident of Bombay think about journeying halfway to Goa to see a doctor?
But if the distance that patients travel is one kind of number that tells a story about health care in these parts, another kind is painted on the low wall that surrounds the JSS OPD building. The wall is topped with smooth black granite, and painted across the surface are regular white stripes, one every couple of feet. Between each pair of stripes is a number.
The OPD clinic is held every Monday, Wednesday and Friday. JSS’s doctors—Drs Jain, Kataria and others—work hard, but they cannot keep up with the crowds that stream through their gates every day, many hoping for a OPD visit. On the Monday afternoon when we arrive and start getting acquainted with the place, there are people laying claim—with bags, bundles of clothes, firewood, and in one case even a crutch—to the numbered spots on the granite wall. For that’s what the stripes and numbers mark out, the queue to see a doctor in the OPD.
But this is not the queue for Monday. Most of today’s patients are either already inside the clinic or have been seen and discharged. This is the queue for Wednesday’s OPD clinic. In fact, some of these patients would not make it into Wednesday’s OPD either. They will not see a doctor until Friday .
Many patients come to JSS with their families, and many of those families bring bundles of firewood: while they are here, they will cook meals for themselves.
Whenever he gets a few moments, Dr Jain consults a large book called “Medical Emergencies in Children”, by Meherban Singh. This woman is no child, but this text addresses poisoning emergencies too. Still, he does not find enough in it today to help beyond what they are already doing, so he makes a call.
“Is that the Poison Control Cell in Delhi?” he asks. “I’m Dr Yogesh Jain from Ganiyari, calling regarding a patient we have with endosulfan poisoning.” There is a pause. “I’ll tell you the details later, tell me the treatment first.” Another pause. “OK, her name is Sanjana Patel.” Pause, enough for some of us to roll our eyes at each other and wonder why the Poison Control Cell needs to know her name? “We don’t know when, probably in the morning today.” Pause again. “She’s having regular seizures in spite of metazolam, infusion and thiopentone drip.” Pause. “Have you heard of any reported successes?”
Dr Kataria’s phone rings, loud and startling in the quiet of this room. Annoyed, he yanks it from his shirt pocket and mutters, “Can I call you back? I’m with a patient who has been poisoned.” Stuffs it back in his pocket.
Dr Jain disconnects and turns to us. After listening to him spell out how she is being treated, the Poison Control Cell suggested they try using colestyramine.
Colestyramine is a drug that binds to the pesticide and prevents its re-absorption into the body. But JSS does not have the drug. Unlike endosulfan, it is not easily available in these parts. At any rate they will never get it in time to treat Sanjana. The Poison Control Cell finally recommended fruit juice. Dr Jain shrugs, shows his palms, smiles a perplexed smile.
On the cover of the June 2010 JSS “Report of Activities” is a photograph Tom took during our visit there. It’s a shot of a pair of male legs, bulging at the knees but otherwise the same thickness—or thin-ness—all the way from ankle to upper thigh. You can see the man’s dhoti and the bottom of his thick grey jacket. His two arms hang at his side, the hands like large claws. He is standing on a bright blue weighing scale, and if you squint you might even be able to read the numbers on the scale.
But you do not need to squint. Inside the front cover is this caption: “Dhanga Baiga, 55 years old, suffering from tuberculosis and chronic hunger. Weighs 28 kilos. Body Mass Index 10.9, considered too low to be compatible with life.” Those last few words could not be more accurate. You would be hard put to find a discussion of BMI in which numbers like Baiga’s even figure. One, for example, describes as “severely underweight” people with a BMI less than 16.5. Baiga is a generous one-third less than that. It also says that a person 1.8m tall—more or less Baiga’s height—with a BMI of 16.5 would weigh less than 53.5 kg. Sure enough, he does weigh less, almost half as less.
Put it this way: At 11 years old and nearly a foot shorter, my son weighs nearly 10 kg more than Baiga.
There’s plenty to note in this Report of Activities, on nearly every page, about JSS and its work. They run “three subcentres in three forest village clusters … which serve more than 150 forest and forest-fringe villages.” These subcentres are 50 or more kilometres from Ganiyari.
They are each operated by two health workers from the area, trained to address basic health issues. JSS doctors visit every week and hold clinics to take care of more serious cases. This is the only health care available to residents of these village clusters. Dhanga Baiga came to one such clinic, in the village of Bamhni.
The report speaks of “technologies [JSS has] developed or adapted … to diagnose and treat people.” This is necessary because of the high cost of even basic medical equipment. So among the technologies they have worked on are thermometers, stethoscopes, breath counters and even weighing machines. It’s one of those that Baiga stood on in Bamhni to find that he weighed 28 kg.
The report has a section titled “Addressing Specific Diseases”, mentioning “chronic hunger, malaria, tuberculosis, leprosy, diabetes, hypertension, cancers, sickle cell anemia, rheumatic heart disease, congenital malformation and animal bites.” It is a commentary on both the state of health care in this area and of JSS’s approach that they consider both hunger and animal bites as diseases.
If all that says things about JSS, two sentences on page 3 may best capture its spirit: “The primary objective of all our activities has been to address the inequity in health. The strategy we have chosen is of providing health care.”
These two sentences speak volumes about the state of health and health care in the JSS catchment area and the indifference of the Chhattisgarh government. That’s the context in which to consider Baiga. And that is what we are seeing with this woman in a crumpled yellow sari who has tried to kill herself with a pesticide.
Her husband, Satish, has arrived from the kiln and is standing at the door, looking in. He wears a striped shirt, a tie-dyed cloth around his neck and shoulders and a small assortment of bands on his wrist. He is a short man with a sparse moustache and large eyes, youthful like a schoolboy, shell-shocked by the sight of his wife on this table.
Standing on either side of him are the two men who brought her here, Tarachand and Rakesh. We learn from them that when they realised what she had done to herself, they first tried, using an egg and salt, to induce her to vomit. When that did not work and she fell unconscious, they had only one thought: they needed to get her to a doctor, and quickly. However, they did not go to the Ganiyari PHC. They travelled six or seven km to reach Ganiyari from their village, Ghutku, the three of them on Tarachand’s motorbike, Sanjana between the two men. By the time they reached Ganiyari, it had been 20 minutes since she took the endosulfan.
Satish, unable to speak, only watches and listens. It’s Rakesh who tells the doctors that Sanjana and Satish have four kids, between 6 and 10 years old. Four kids who might be motherless very soon.
The doctors have no time for futile thoughts like that. On the table, she is into a new seizure. Watching her strain and pull again, Dr Vikas Singh, a younger doctor on a short-term internment with JSS, asks if they should give her a muscle relaxant. Dr Kataria thinks it will not help. Dr Jain repeats the odd instruction the Poison Control Cell offered: fruit juice.
“There is no spontaneous respiration yet,” he says. She is breathing only because they are ventilating her, not on her own. If she stays on here at JSS, they will have to keep ventilating her by hand, for that football-shaped pump is the only equipment they have for the job. This is clearly impossible, as the doctors estimate she will need oxygen for at least seven or eight hours more.
So they decide to send her to the medical college hospital in Bilaspur, 20 km away, where there is an automatic ventilator. It is probably her only hope of survival, though there may be oxygen deprivation damage and other side-effects from the drugs they have flooded her with to battle the poison.
Sanjana keeps convulsing. The nurse keeps pumping the football. Dr Jain looks again at Meharban Singh’s book.
To a lot of people in India, Chhattisgarh is now synonymous with the Maoist unrest. Mention the state’s name and eyes might widen involuntarily. Tell friends you are going there and they will ask in low voices: “But aren’t you afraid of the Naxalites?”
Maoists now operate in a large swathe of Indian territory, like the stroke of a paintbrush across the middle of the country. Whether that makes it more or less safe to travel in those areas is debatable, but there have been plenty of battles between Maoists and the police, causing many deaths on both sides.
In April 2010, for example, Maoists killed 74 Central Reserve Police Force (CRPF) personnel in an ambush in Dantewada in Chhattisgarh. What is pretty clear is that Indian government is effectively absent in these parts. Yet that’s a situation that predates the Maoists, and is too familiar to too many Indians to be a surprise.
Justice, health care, education, governance, these are themes that might as well be foreign to the people who live here. No government has cared to address them, and this helps explain the support Maoists get. Today, the paintbrush covers part of Chhattisgarh too. But the districts that the Maoists control, the now nearly-folkloric names of Dantewada and Bastar, are in the southern reaches of the state. If you are visiting JSS you are safe, Ganiyari is a long distance north of the tension and violence. Even so, what our visit does for us is invaluable. Even a quick look at the work of JSS serves to open our eyes about conditions not just here, but in rural India in general.
The Chhattisgarh government runs a programme for its poorer residents under which they can buy up to 35 kg of rice a month at Rs 2 per kg. Yet the better measure of poverty in Chhattisgarh is a memory from visiting villages, like Bamhni, where JSS runs outreach clinics. While the doctors met patients, I wandered about and spoke to residents.
Almost every house—certainly more than 80 per cent of the many dozens I walked past—had a red notice painted beside its front door. It confirms that the family is eligible for rice at Rs 1 per kg. That is, the family is too poor to afford rice at even the Rs 2 price.
In one random sample from a random pocket of a decidedly non-Maoist section of Chhattisgarh, easily four of every five families are that poor. That is the scale of the kind of poverty that is too easily seen in India.
As they work, the doctors keep up their steady discussion about what to do next, what drugs to give her. I know the two senior men especially, have years of training and experience to call upon. Even so, the impression they give is of addressing the situation not with jaded formulae from medical school, but with fresh minds, thinking on their feet. While their calm professionalism is impressive and reassuring. I cannot help a quick thought about the difficulty JSS has in attracting talent.
Conditions in Ganiyari are hard, the pressure is relentless. Nearly every day throws up fresh crises that interfere with plans for meetings, training programmes, or documentation. The pressures of their work often travel home with them, and there are the usual issues to think about; of the kids’ schooling, and indeed of life itself in this dusty backwater of India. These doctors gave up the chance of high-profile urban careers to come here, to work like this.
And when they respond to this poisoning emergency, you can see why. Hard work it might be, but it is greatly fulfilling too, working among the people who need their care the most.
Yet these doctors are all approaching 50. In the years since they set up JSS with their enthusiasm and idealism, no younger doctors have wanted to join them. No younger doctors have been fired with that same zeal, attracted by the same chance to immerse themselves in satisfying work. What is the future of JSS, then?
The nurses lift Sanjana onto a stretcher and wheel her to an ambulance parked outside, a Maruti van on whose rear window there is a large image of a dog peeking from under a blanket. The football-like pump and the drips scurry alongside. Curious onlookers gather silently to watch.
Satish climbs in after her and sits, hands red from the kiln, now nervously clutching both drips. Rakesh sits beside him, one hand on his knee. Through the window, Dr Jain suggests that her legs be folded. With all the weight, the Maruti van sinks visibly. Then it moves off, stops outside the gate for a minute, moves off again.
Watching them go, Dr Jain has a final observation. Pesticides like endosulfan that have no antidotes, must not be freely sold. Period. Tarachand, the motorbike owner, is still here. Dr Jain remembers him coming through the gate like in the famous scene from the film 3 Idiots, Sanjana sandwiched between the two men, head lolling, arms flung out to her sides, convulsing as they stopped.
Dr Jain thanks Tarachand. Tarachand shakes our hands and turns to walk away. The back of his shirt is covered with blood.
Days later, Dr Yogesh Jain sends me a text message. Sanjana survived. A week later an email message from one of his colleagues tells me she has “gone home fully recovered from the poisoning”. She has since returned to JSS for other minor complaints. She referred once to the poisoning, just saying that she was angry about something and had swallowed the endosulfan on an impulse.
The same email message speaks of a new emergency: an eight year-old son of contract labourers in Madhya Pradesh who was bitten by a rabid dog. The contractor, anxious not to lose their services, told them “not to worry”. So the parents waited for 12 days before bringing the boy to JSS.
Dr Jain tells them to “take him home and keep him comfortable till he dies”.
The message ends: “And so it goes.”
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