Two days in south Rajasthan with AMRIT Health Services, a not-for-profit initiative
“The demand to sacrifice a goat was not something we had expected as a precondition for setting up the clinic,” Dr. Pavitra Mohan explained. A pediatrician and public health professional, he was telling me about the initial days of setting up the first AMRIT Clinic in Bedawal, a Meena village in south Rajasthan that otherwise had no healthcare facility. The problem was that the building he had identified as adequate for his purpose was directly across from the village temple to their god, Hemliya Bavji, but it required major renovations, including the construction of a toilet, apparently the first in the village. Though the panchayat welcomed the clinic, several villagers refused to allow a toilet so near the temple, on religious grounds. To make matters worse, they also refused to allow trimming the sacred tree overhanging the building in order to build rooms on the roof for the healthcare workers to sleep at night. But after further talks and negotiations, they finally granted permission to build the clinic and trim the tree as well.
And so, in early 2013, AMRIT Clinic opened in Bedawal with a small team of qualified nurses and healthcare workers, who constitute the core of AMRIT Health Services (AHS) in the villages. They are supported by a doctor who visits once a week and is also available for telephone consultations on other days. Hoping for a view into the work of this organization—its context, its challenges, its benefits to the local population—my partner and I went for a visit in early August; our plan was to produce an introductory video about their work.
With Dr. Mohan, Niti Sharma, Manager of Operations, Himi, Fellow, public health, and Dr. Gargi Goel, a young pediatrician who had come out on a job interview, we drove ninety minutes from Udaipur city to Salumbar, the last little town where basic services—petrol, meals for purchase, rooms for the night—were to be found before we headed out into the fairly isolated villages of the remote countryside. From Salumbar, we continued for another forty-five minutes on narrow, broken or dirt roads to Bedawal, the first of two clinic sites we visited.
With little vehicular traffic, buffaloes and goats took up the slack. An occasional bus or jeep rattled back toward Salumbar, overloaded with people sitting on top or swinging off the sides, as this was their only available transportation. Maize stood tall in small plots receding into the hills and valleys on both sides of the roadway, and squatting among these fields were mud and stone dwellings with broad verandahs and rough tiled roofs supported by carved wooden beams and lintels. Droves of children in shabby school uniforms—mostly boys—milled along the roadside near the village center, laughing, playing. Electrical wires were stitched across the landscape, but we learned that much of the time they are dormant, sometimes for days. For me, arriving from the sticky heat of Delhi, the cooling breezes of this region’s modest elevations and its fresher monsoon air were invigorating.
Despite the goat sacrifice, Himi told us, one of AHS’s early challenges has been to gain the trust of the local people. There had never been qualified medical practitioners in these villages, but a particular brand of charlatan, known locally as Bengali Doctors, preys upon the people, charging hundreds of rupees to put patients on a saline drip and inject a drug cocktail that gives them a jolt, no matter their ailment. When villagers first came to the clinic, they expected the same treatment and were suspicious or dismissive if they did not receive it. And when the nurses asked only fifty rupees for a week’s treatments, the villagers scoffed. What kind of medicine can be so cheap? “Then they were afraid we might do some magic on them,” Himi said. Fortunately, as more and more people have been helped or cured by the efforts of AHS, the perceptions are changing.
This region is populated primarily by Meena tribals, members of Rajasthan’s largest tribal group. Their origins are uncertain and reliable information about their past is scant. But it is undeniable that today the Meena people of Udaipur District live a marginal existence, systematically ignored by government bureaucracies. Though they have given up nomadism, they do not yet seem to have developed a complete and sustainable settled agricultural lifestyle. The range of foods they have access to is nutritionally narrow, entirely lacking in vegetables and fruits. Their livestock husbandry yields little benefit.
Women farm a small corn crop during the monsoons, and some plant an additional crop of wheat during the winter, but these subsistence crops are insufficient and available for only part of the year. They may keep a buffalo or cow, but these too are starved creatures during most of the year, producing little milk from the arid vegetation. A few chickens produce occasional eggs. They can get fish from the local lakes. But like most women in such marginal communities, a good deal of their time is spent in gathering firewood, fetching water, and feeding babies.
The men and boys as young as fourteen migrate seasonally to Ahmedabad, Mumbai, or Jaipur to join the great class of migrant laborers who move by the tens of millions between rural and urban India, performing low wage manual labor on construction sites, factories, warehouses, and elsewhere. In addition to their poverty, they become non-persons when they cross state lines, lacking official papers and being of no interest to local politicians who do not count them among their vote banks. It is the crowded and unhygienic living conditions and harsh, unyielding, and dangerous work that the men endure as migrant laborers, in addition to their poor nutrition, that makes them especially vulnerable to illness. Often the men return home with TB, HIV, serious injuries, and other severe health concerns that cut short their working life.
The clinic in Bedawal is four small rooms, including the examination room, the waiting room, a delivery room, and a central area, stacked high with medicines and medical paraphernalia. Groups of women and children bathed at the pump-well outside. The delivery room, with its single bed, is currently in use as lodging for the women who worked at the clinic, on call twenty-four hours a day, until they can move upstairs when the construction of their rooms is completed.
Several patients waited silently, exhaustedly, on the window ledges and floors or lounged on a bed in the narrow front room, tended by two nurses dressed in purple vests, and a health worker. All of the patients were slightly built, clearly owing to hunger, malnutrition, and wastage from disease. Many of the children had flaxen hair or flaxen streaks, a mark of malnourishment. Iron levels in this population are so alarmingly low that immediate blood transfusions are indicated for many of these patients. But there was no possibility of such a treatment here, with no blood bank, no qualified blood donors, and no one to pay for dozens of transfusions for people whose root problem, malnourishment, could not be addressed.
The nurses and healthcare workers who ordinarily run the clinic had queued up several patients for the doctor to see during his weekly visit. About twenty patients showed up that afternoon: two men recovering from TB that had left them too weak to walk, until the intervention of AHS; a boy with a hole in his heart, wasted limbs and expanded chest, his eyes appearing overlarge in his drawn face; a thin, yellow-haired toddler who had burned his leg on hot coals when he tumbled into the open hearth; an old woman whose joints had locked up with advanced arthritis, now able to move a little since she had been receiving treatment; a newborn with septicemia, his young mother staring vacantly in silent anguish. Though malaria is common in this region, we did not see any cases on the days we were there. The patients speak a dialect called Vagdi, a blend of Mewari and Gujarati, which the doctor has picked up well enough to converse with them, but the nurses also translate and make certain the patients and the doctor understand each other.
Our visit coincided with the doctor’s visit, but most days the clinic is ably run by AHS’s dedicated staff of nurses and senior healthcare workers. The staff sees patients in the clinic and determines which cases should be brought before the doctor on his weekly round. However, many patients cannot or do not come to the clinic at all. To reach them, Himi and the healthcare workers make house calls, check their progress on follow-up visits, and deliver medications. They also lead an outreach effort to track the health and weight of newborns, and to train local women in recognizing common conditions such as malaria and cholera, administering first aid, disinfecting water wells, and disseminating information on nutrition, hygiene, and birth control. These village outreach workers are called Swaasth Kirans, or Health Rays, for their role of extending the reach of healthcare to every home of every hamlet in the vicinity. The clinic becomes a healthcare hub, with health delivery radiating outward through the efforts of the healthcare workers and Swaasth Kirans, who educate those around them.
I was moved by the enthusiasm, self-confidence, and sincerity with which they spoke about their roles in the community, their desire to spread knowledge and uplift their village. One senior healthcare worker told us she uses her cell phone to snap photos of ailments that she can later show to Dr. Mohan. It was clear that whatever the initial fears and perceptions of the villagers regarding the strangers giving out cheap medicine, AHS's constancy, care, and dissemination of information have started building trust and energizing the community toward better health. The goal of AHS is to hone the model at Bedawal and Manpur and then extend it to four more locations next year, funds permitting.
The Aravalli hills are said to be the oldest mountain range in the Indian subcontinent, the former peaks long since ground down to jagged nubs, jutting like crocodile teeth above the softer undulations of domesticated valleys and rounded hillocks. Ancient fragments of shattered stone cover the hillsides. Scrubby brush, low grasses, and occasional succulents grant an austere green to the semi-arid landscape. But in Udaipur District, the southern reaches of the Aravalli range are indulged with loose stands of teak forest and broad, lake-filled valleys scattered unexpectedly among the rolling savannas. And now, during the monsoons, the land is transformed by ostentatious viridescence, though this surge of green enjoyed by the buffaloes will fade back to its more somber tones with the end of the rains.
We stayed overnight at a guest house in Salumbar and set off the next morning to the AHS clinic in Manpur, an hour’s journey across rough roads. The clinic is perched on a hill overlooking the village houses and fields. But even as we admired the calming scenery, the AHS staff remained busily engaged within the clinic, barely pausing to have the lunch we had packed with us from Salumbar. They saw over fifty patients over the course of that long day; no one was sent away without due attention.
I wondered how overwhelming this must be for the doctor on his weekly visit, deluged by patients, illnesses and complications beyond his specialty. I thought of the nurses and healthcare workers who lived in the clinics, always on call. How exhausting! A couple of nurses had defected within weeks of completing their training, unable to persist under the conditions, the isolation, the lack of electricity and other services or amusements of any kind. Niti, the Manager of Operations, had told us that apart from transportation issues, retaining the talent was their greatest challenge, though the nurses were paid at rates competitive with nurses in cities. Himi, from Jaipur—a dental surgeon by training who wished to make a career in public health—had stayed on, living in Salumbar, already isolated enough, but she was a rare find motivated by an irrepressible desire to help. Nearly all of the nurses and other healthcare workers were locals.
But there were no local doctors, and AHS had not yet been able to attract one to take over the responsibility of weekly rounds from Dr. Mohan, so he could concentrate on setting up more clinics. Though now here was Dr. Goel surveying the situation. I wondered what she was thinking. She was keeping too busy to ask right away, having jumped into the effort like it was her natural element. But then she had been a practicing physician for some years. “When the patient is in front of you, that’s all you think about,” she had said.
In the mornings, we observed the nurses and the doctor in the clinics, and in the afternoons, we followed Himi and the outreach workers on their visits to village homes. Two visits were post-natal follow-ups to check on the growth and health of new babies. In one case, the baby, who had been born with low birth weight but had gained well over the previous months, had suddenly lost 200 g; her mother was not to be found, though while we waited the healthcare workers stressed to the hapless grandmother the importance of breastfeeding the child. They counseled the other young mother, whose newborn was doing well, but whose two other children were underweight, to feed the older ones vegetables, milk, and eggs, and to consider having no more children, to all of which she nodded. Many women are glad to stop having more children, ideally after they have achieved two sons, but they lack knowledge about reliable birth control.
We met a man whose life had been devastated by Hansen’s disease, also called leprosy, which made him a social pariah, preyed upon by villagers who abused and attacked him out of fear. But the outreach workers had cared for him, checked up on him, made sure he persisted in the long treatment for his condition, and the disease was arrested before it took any of his fingers or toes; only his nose and mouth were deformed. Ramlal, a native of Manpur, spoke with great passion about how the work of AHS had given this man and his family a second chance at a life. Their gratitude was palpable as Ramlal translated their Vagdi into Hindi.
Dr. Goel emerged from the clinic before Dr. Mohan in the evening. She had recently resigned from Medanta, a high-end, private hospital catering to the upwardly mobile classes of Gurgaon, in hopes of pursuing more meaningful work, something where she felt she was serving the people. “I must do this,” she told us. “I must follow my heart. I will figure out in my mind how to live in this rural place. I still need more training. But I must do it.” Her only concern was what her parents might say. “They will support me,” she decided after a thoughtful pause. “I will just ask Sir to meet them.” It amused me to imagine where else a job interview might end in a request to come home and meet the family.
Dr. Goel will have plenty of good company at AHS, an uncommon assortment of people dedicated to helping those who most need it, despite the demands and hardships of the task, despite the immensity of the problems to be solved. “I know I am not perfect,” Dr. Goel said. “I will make mistakes, but I have to try. There will always be problems, but okay, we must try to solve them.” That is the only way anything ever gets done.
Update 05 October, 2013: Watch a video story (14 mins) on the work on AMRIT Clinics.
AMRIT Health Services are a collaborative initiative of Aajeevika Bureau and Basic HealthCare Services. Aajeevika Bureau is a specialized not-for-profit organization set up to provide solutions, services, and security to seasonal migrants who leave their villages to work in cities, farms, and factories. Basic HealthCare Services is a start-up not-for-profit organization that is driven by the vision of a responsive and effective healthcare ecosystem rooted in the community, where the most vulnerable can actively access high-quality, low cost health services with dignity. Dr. Pavitra Mohan is the founder of Basic HealthCare services and Director, Health Services at Aajeevika Bureau.
Usha Alexander is a writer, instructional designer, and erstwhile student of anthropology and natural sciences. She currently lives in Gurgaon, India. Only the Eyes Are Mine is the title of her first novel.