“Sir, would you like to have some black tea?” My co-medical officer translated for me. It was a time when I did not understand the language of ‘Gondi’. “Definitely”, I replied. I am always open to any kind of tea or whatever served under that name because I just love the idea of tea!
I have always felt that as doctors, we are respected in tribal villages not because we are of any use to them but because we were able to complete some kind of higher education. Of course, when you think about it, any lineman from the electricity department or Gramsevak (agricultural extension worker) would be of more use to them than us. Probably, one of them would have been offered fish or chicken instead of the tea which was being offered to me, a doctor.
We were in a village and it was one of those rare occasions when three medical officers had come to visit their houses. Obviously they wanted to welcome us. The person who offered us tea had lost his son a few days back probably due to malaria. Presumably, we (I mean the health system) had some role his untimely death and now we were there investigating the cause of the child’s death. During the informal discussion that followed, we also came to know that his wife had delivered, probably at home, and their newborn had also died.
“Sir, is the sugar okay?” the person asked again. He was standing in front of us waiting for our feedback on the tea with great respect for us reflected in his eyes. We were the doctors who had come all the way to visit him in his village. In reality, we were the doctors representing the government health system that was partly responsible for the deaths of two of his children within a span of less than a week.
I always envied those people around me who had this great ability to “empathize” with the problems of others. I am very bad at empathizing. I couldn’t imagine counseling someone over a breakup or a low grade in some stupid examination. But, when I remember such incidents and there are more of them, I still get shivers. I have always wanted to ask a question to those “good hearted people” who romanticize the situation in tribal area and do not want anyone to ‘disturb the tribal culture’. ‘At what age and how will you let a near one die?’
I am writing this piece for a health equity web portal and so I’m going to use this opportunity to share my experiences with the concepts of ‘equity’ and ‘efficiency’ in health. Trust me readers I have struggled a lot in the past with these ideas, though at that time I didn’t know what the jargon meant. But the concepts were quite commonsensical.
I started working in a tribal area immediately after completing my MBBS at which time I had never thought of public health as a career. It was more of an emotional decision to give at least two – three years of my life to the cause. This decision had happened mainly because of an exposure during my medical education (I volunteered and later became a coordinator in one of the initiatives in one of the tribal belts as a medical student) and also due to the influence of a renowned public health professional.
My first encounter with equity happened when I was posted in a PHU (a Primary Health Unit and not a PHC) in one of the most backward and Naxal (members of the ultra-left Marxist Leninist Party) affected districts in that state. By the way, the word “remote” always confuses me. What is remote? I don’t think any district place in India can be really called remote. I am saying this because people take so much pride in working in remote areas when they actually spend most of their time in the district headquarters. For me, villages which are not yet electrified (doesn’t necessarily mean not having electricity) are the ones which are really remote (seriously, the electricity department has the highest penetration).
A Primary Health Unit (PHU) is not the norm; it is designed for the remotest places. The PHU I worked in served a population of less than three thousand which is less than the population covered under any sub-center in a plain area. This is the public health system’s way of making availability of health services more equitable: having a lower population to health facility ratio. Does it really help? The three thousand people from tribal communities lived in eighteen different villages with an average population size of less than one hundred and seventy and the remotest village was forty kilometers away from the PHU. The lesser the said the better about connectivity and network (even in PHU). Most of the villages did not have “pucca” roads. It cannot reasonably be expected that patients would visit a health facility from such geographic contexts (forget about the cultural and economic contexts). My daily patient count was less than five!
At the PHU, I often wondered what I was doing. Was I wasting my time? Could have I done much better in any government district hospital if my objective was just to serve disadvantaged people. Was this an efficient way to spend my time? There were also those few tricky moments where I had almost decided to quit.
Let me now talk about my struggle with the concept of efficiency. I haven’t come to terms with it, since I am still struggling with one side of the equation of efficiency, which is that of output. What were the outputs that we expect when we envision a state of efficiency? When an ANM climbed two hills and spent her whole day to immunize a child, what have we achieved? When I treated those five patients who visited my PHU in a day what had I actually achieved? Cases averted? Coverage achieved? Was that all, or was there any other dimension (z-axis) that would give more meaning to our effort (which will help define the output that we were seeking). I still don’t have an answer.
At that time, in order to decrease my restlessness I rationalized that if when deciding my diet I didn’t go for the cheapest of the many available options to meet my daily energy requirement of 2800 kilo calories and other nutrients, then there was no need to be so rational about expending health resources either. Governments, which are always though to operate under “resource constraints”, had to look for the cheapest options. However the question remained - the cheapest option to buy what? Also, there were so many things that governments did routinely that we never even think of questioning from the efficiency lens.
So, did the supposedly “reduced” physical distance between tribal communities and health care, achieved through more number of institutions and increased manpower (on paper mostly) really result in an increase in utilization of heath care? Yes, it did (remember, my five patients per day). But to what extent and was it really the output that we sought?
Let me share with you another experience. Up until this incident, I had considered myself a good athlete and had represented my medical college in a few sports events. But, there was an incident in the village when I was outrun by a tribal woman. Why was I chasing her? I just wanted to prevent another maternal death by referring her to the district government hospital. The woman who outran me was a nine-month pregnant woman who was at high risk. I had never seen such desperate attempts to get away from health care system. This woman had jumped the one foot tall fence and run out into the forest. Seriously, what did we doe in the hospitals in our efforts to “save their lives”, which resulted in such fear?
People from tribal communities may be short of material goods but are respected individuals in their communities. We shatter their dignity during their rare encounters with the hospital, be it in the labor room or a consultation room. The excessive contempt and disgust with which health professionals viewed them was something that they had never experienced in their entire social life in a tribal village. One visit to the hospital was sufficient to destroy all their pride. For this very reason, I had been always afraid of referring patients to the district hospital during my tenure as a medical officer in the Primary Health Unit.
One cannot discuss tribal in the red corridor without mentioning Naxalism. Yes, we all know that it’s a developmental issue.
Before giving my opinions on this sensitive issue, let me give you a disclaimer. I am not very familiar with their ideological basis and also with relevant literature (like that of Charu Majumdar), but I still have few things to say. It is true that Naxalites never opposed the health services and I never had any personal bad experience with them during my stint with them. But being a citizen in a democratic country, if I was asked to vote (in our country anyone can vote irrespective of his/her maturity) then at this moment, I would vote against Naxalism. But that definitely didn’t mean that I was for the government, as the choice is not as simple as it looks.
From my little experience I could find neither the Naxalites nor the military being helpful to the tribal in any way. I could never justify their means in any rational way especially after what I had experienced. I had seen six innocent tribal people (at least for me) being killed on six different occasions by the Naxals. I knew all them personally; one of them was my friend with whom I used to play volleyball regularly. He was killed because he dared to organize the villagers so that the village would get electrified for the first time since independence. A policeman was killed in front of my eyes and I could not do anything. My stupid ignorant brain could no longer see any larger good which helped justify these killings.
My experiences of working with tribal community have given me the strength to venture out of my comfort zone and make those harder choices. To sum up, all I want to say is that all of us have heard about Gandhiji’s talisman:
“I will give you a talisman. Whenever you are in doubt, or when the self becomes too much with you, apply the following test. Recall the face of the poorest and the weakest man [woman] whom you may have seen, and ask yourself, if the step you contemplate is going to be of any use to him [her]. Will he [she] gain anything by it? Will it restore him [her] to a control over his [her] own life and destiny? In other words, will it lead to swaraj [freedom] for the hungry and spiritually starving millions? Then you will find your doubts and your self melt away."