Ganiyari

A few years ago I spent some time in an obscure village in India called Ganiyari. Ganiyari was like most Indian villages, small and unremarkable in most ways; except one. Sometime in the year 2000 a diverse group of highly trained doctors, all from what is considered the Parnassus of training institutions in India, the All India Institute of Medical Sciences, had at the end of a long and gruelling emotional, philosophical and geographical journey finally set up shop in Ganiyari. The four men, a paediatric oncologist, an internist, a paediatric surgeon, and a microbiologist were not quite your average, run of the mill doctors. Besides distinguishing themselves academically they went a step further reflecting on medical practice and the state of health in India (natural you may think, but in fact unusual in their context) and gave up what could have been highly lucrative practices in any metropolis for a life in rural India, a place they felt ‘they were actually needed’.

JSS Village Program - Ganiyari in the lower right corner

Coincidence and possibly some foresight had it so that they each married medical professionals too. Add to this already impressive mix another internist, another paediatrician, an obstetrician-gynaecologist and an ENT surgeon. This rather opportune of combinations led them after much scouting to Ganiyari, situated in one of the poorest and underdeveloped states in India, Chhattisgarh. Here they managed to rent out an old, abandoned public utilities building and the small piece of land attached to it. After much restoration to the crumbling edifice, they set up a 15 bed ward, outpatient clinics, a delivery room, an operation theatre, and even basic laboratory services thanks to the microbiologist, who also ensured asepsis. They also had outreach clinics once a week in nearby villages. They called it Jan Swasthya Sahyog (JSS),

The Jaanchkaksh or Laboratory

loosely translated as People’s Health Collaborative. Ganiyari was close enough to a small town, Bilaspur where they were able to stay with their families and commute daily to the hospital, one or the other being on overnight call. The intention initially was to stay on the premises, but I hear the wives objected and with persuasive arguments about the children’s schooling convinced the men to hunker down in Bilaspur. 

By the time I joined them, a good 7 years later, they had expanded to a ‘theatre complex’ with two large, bright theatres, (right above which I was given a room), had x-ray and ultrasound facilities; bed numbers remained the same though patients would put their heads down wherever there was place (and you had to be careful not to trip on them when called at night), and clinics at ‘nearby villages’ had grown into a health worker program with outreach clinics as far as a 100km away, scenically situated on the top of a mountain amidst dense forest, and which was a nightmare to get to on the dirt tracks. They also had a few ‘junior doctors’ like me willing to slave away for a while early in their careers, hungry and eager to learn. And most important was a new and much improved ‘International School’ in Bilaspur for the children. JSS had grown in popularity, largely due to an archaic and nearly extinct public health system which often if not always failed to provide adequate care, but also due to the competence, range of services and high standard of care at incredibly low prices. Outpatient clinic cost Rs 7 for the first visit and Rs 5 (10 Singapore cents) for subsequent ones. Costs were kept low by meagre salaries, generic drugs, many low cost innovations (including the substitution of a junior doctor for neonatal ICU services) and some small donations. 

An 'Easy Read' thermometer for the health workers with
abnormal temperatures marked in red

My time here was to put it mildly, phenomenal. I could write pages on the medicine I learnt, the cases I saw, the real life versions of textbook medical problems that we had been lulled into believing were a thing of the past. My first ever case of exomphalos woke me up at 2:30 am. My groggy first glance almost caused me to yelp out loud as I saw this 800 g baby, barely breathing, almost as cold as ice, lying in a basket because the parents were too scared they would harm her if they tried to touch her. She had been born the night before; the parents had set out at break of dawn and travelled all day and almost all night to get here because of the miraculous doctor they had heard about (our paediatric surgeon), but she hadn’t been fed a thing. We operated, and she survived, giving me another nightmarish night as I waited and waited (and waited and waited) for the first few drops of urine to form. She was lucky; many others I saw in very similar circumstances didn’t fare so well. It was very common practice for patients to turn up at our doors this late at night. They often came from very far away, and would travel many, many kilometres through the day, a large part on foot, before they reached us in the middle of the night, giving us juniors the kind of night calls we’d never experienced as interns. 

Health Worker Pamphlet on identifying poisonous snakes in the area

I learnt a lot, to say the least. I saw all sorts of cases, connective tissue disorders, rheumatic heart diseases, valvular disease, cancers of all sorts (once again too many cervical cancers than there should have been, we diagnosed them by nose; by the smell of so badly a fungating and infected growth that they had finally been forced to seek health care. We could smell them as they sat waiting patiently on their benches, the OBGYN would simply look up, sniff, point and they would be ushered straight into the examining room ahead of everyone else), a lot of sickle cell anaemias, some thalassemias, poisoning, animal bites, the insidious nutritional anaemias, skinny diabetics (so many that I almost thought the rah rah about obesity a joke), cleft lips and palates, hernias, hydrocoeles, you name it we saw it and if I could, operated on it. 

A typical Phulwari (Day care centre) - Sarees hung from the beams served as swings by day and cradles for the little  ones to sleep in the afternoon

What left a lasting impression on me though was not as I may have implied the knowledge I acquired or the medicine I learnt, but the people I met, and the stories they told me. Why it was that the smelly woman with cervical cancer had come to us so late, why it was that the fifteen year old boy had caught falciparum malaria (the first death I ever certified) in the middle of winter and not the monsoon as was believed to be common, about the siblings with severe rickets, about families full of XDR TB. How when food was scarce and money even more so I was always given tea, lunch and biscuits in every village I visited. I loved to listen and watch as young fathers proudly held their new born daughters and told their neighbours that boys were useless these days, girls would always take care of you.

Most of the stories were sad, of a young 23 yr old woman who fell off a tree plucking mangoes for her little children and died after three days of agony, of a young farmer consuming cans of pesticide in an attempt to escape the trials of this life, of a mother insisting her dead son was still alive because when she held his hand he was still warm to the touch. Some were amusing like women who had had so many children that they often gave birth while at work in the fields or jungles, fed the child and then just carried on working brining the little tyke home at dusk. Some were ironic, like the time I was invited, big city girl that I was, to bathe in the river with the local women and then told that this was one of the last few times they would be bathing here since the government had seized the land their village had stood on for generations in the name of conservation, or of the cholera epidemic that converted our little hospital to a war zone punctuated with gallons of ORS in which we proudly claimed we had not a single fatality except for the two abrupt miscarriages. In the midst of all this strife the stoic resilience of the people never failed to amaze me, the determination that life must somehow go on, that we must continue to provide for the children we have left, the parents we owe everything to, and give them a better life than we could ever imagine. It’s these kinds of people that Philip and Mikael will meet as they travel through similar places. It’s these kinds of stories that they will hear and I hope will be able to tell, of despair, and hopelessness, of resignation and sufferance, of the depth and strength of care and love, of the undying will to keep going on. Because no matter what their story and how it ended, with a chuckle or a tear, it was worth listening to, worth retelling.