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’.
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| 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),
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| 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.
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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.
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| 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.
I had got to the Nottingham unit on the recommendation of a
former colleague of Prof Blamey’s who had told him that “this boy has the
irritating habit of asking questions – please see what you can do with him”. The likes of Blamey and Veronesi were not
called clinician – scientists then, but that describes them perfectly. After my short time with them I came to
understand how just doing the clinical service was not ever going to be enough
for me. There were daily encounters with
patients who deserved better answers than the ones we could offer. I would explain the diagnosis of breast
cancer, the treatment options and answer the immediate questions – how much
would it cost, how would a breast conservation breast look like, what were the side effects, what the
survival likelihood; and then that pause as it all sank in. followed usually in
a softer voice as she hopes you’re not going to take this the wrong way, “ So
are those the only options?” “Why is it cancer when I’ve been doing my
mammograms?” “ Are my daughters safe?”
“How long has the cancer been there?” “Is it something I ate?” And at
this clinic when I first tell them their worst fears are now a reality, before
the peace that comes with time and friends and caring husbands and excellent
nurses, at this first clinic that look they give – “can’t you make it go away?”
