What makes you "talkative as a parrot and as cunning as a jackal, then roar and fight like a tiger only to end up rolling in the gutter like a pig?"

The metal trash bin was half-filled with jogri (sugar cane juice) when it was covered with a lid and put over a fire. A tube was stuck into the bin around two-thirds of the way up, connected within the bin to a metal plate that condensed the evaporated gas into liquid when water was poured on top. The liquid flowed from the plate, down the tube, into plastic bins and eventually into a glass exchanged for ten rupees (20 cents), and finally into the mouths of what seems to be the majority of the men in Indiranagar.

Alcohol-making is a job usually done by tribal groups and it is no different in the slum area across the street from CRHP. Tribals had settled in some years back and found that selling alcohol to locals was very profitable. As the villagers began to drink nightly, they wanted something that would hit them harder, that would continually take them to a place further from where they were. In response, alcohol-makers began to put all sorts of things into the alcohol to make it more potent – battery acid, trash, detergent. This local brew of alcohol, or moonshine, is very popular among drinkers, who prefer the low cost and high return to the manufactured alcohol available in town at shops, which goes for 80 rupees per bottle. One glass of this moonshine would seem to suffice for one hell of a night for a typical man, but through conversations with villagers I have found that most drink up to six glasses per day, including in the morning.

In the district of Gadchiroli, however, with the highest ratio of tribals to non-tribals in the state of Maharashtra, it has been illegal to sell any form of alcohol since 1996. A pre-ban survey from the early 90s showed that about 100,000 males in the district were frequent drinkers, 10,000 were addicts and a surprisingly high number died of alcohol-related consequences. In addition, annual sale of liquor in the district was about 200 million rupees while the government’s total annual support for all district development programs was 140 million rupees.

This survey and the subsequent community-based movement to ban alcohol were mobilized by SEARCH (Society for Education, Action and Research in Community Health), a voluntary organization started by Drs. Abhay and Rani Bang in 1986 to provide community care and conduct research on the health of women and children. SEARCH served as my last stop after visiting Sevagram.

The anti-alcohol campaign started through village-level meetings with women and youth to discuss health problems, which elucidated the destruction of lives due to alcohol addiction. Men got drunk, did not go to work, failed to support their families, beat their wives, quarreled, fought and even killed each other. Practically all women seemed to have suffered due to alcoholism among men. Many of the men did not disagree, they just didn’t have the power to stop. Using this high community interest among women and youth, SEARCH mobilized villagers to collect data on the problem and then bring it back to each village to see the response.

As awareness grew, boys in two village youth groups organized a ban on liquor – alcohol stores were closed, bottles were broken, drunks were fined. To bring the movement to scale, SEARCH helped to organize 349 villages to pass resolutions to ban all liquor. Anti-alcohol groups sprang up, including a district-level Darumukti Sangathana (Liberation from Liquor). Making of moonshine stopped but manufactured liquor shops stayed open, invariably owned by local politicians making good money. The people decided they could no longer depend on the government to control alcohol so they partnered with local experts and honest officials to start the People’s Liberation from Alcohol coalition. In 1992, they presented an anti-alcohol resolution supported by 10,000 delegates from more than six hundred villages. In 1996, the state government finally banned the sale of alcohol in Gadchiroli, banning locally-made alcohol and closing all commercial liquor shops. Follow up surveys showed that within two years alcohol consumption was 60% less than it had been before the ban.

There are multiple things that really impress me about SEARCH’s anti-alcohol work. Alcohol was a problem identified by the villagers as something that needed to be addressed and Abhay and Rani Bang took it on full-steam, regardless of if it was a problem they identified. Despite the fact that taboo associated with alcoholism and despite the numerous death threats and jailings they had to endure, they pushed on for the benefit of the community. The purpose of the movement was much larger than their reputation and they were willing to put it all at stake for the benefit of the village. In addition, although alcohol has been banned, they recognize that the problem is not solved and that alcohol can still be snuck in or made under cover. To continue to help addicts who want to quit, they run five-day deaddiction camps with detox in the villages themselves, helping people combat alcohol and/or tobacco addictions. The fact that men attend camps in their own village shows the alcohol-associated stigma has been overcome.

Visiting SEARCH and their deaddiction camp also reinforced a desire to understand the scope of addiction and alcohol abuse in the slum area across from CRHP. Along with a staff member familiar with Indiranagar and the local village health worker, we have begun a survey measuring hypertension, tobacco use, alcohol use and diet among all men in the village. Although going into the survey there was a lot of doubt as to the comfort of men to discuss alcohol, we have so far found that (similar to Gadchiroli) men recognize it is a problem and want to quit, but they just do not know how.

Unrelated, I have posted many new photos onto Webshots if you would like to take a look. Click Here to see them.

Even so, 95% of graduates return to an urban practice or hospital

Sevagram, Service Village in Hindi, is a village 12 hours away from Jamkhed. The village served as Gandhi’s ashram beginning in 1936 and also plays host to the Mahatma Gandhi Institute of Medical Science, where I visited after Kanha to learn about the Department of Community Medicine. The department is doing great work on two fronts: first in motivating and encouraging medical students to practice in more rural areas, not only by force but also inspiration, and second by working to build the capacity of the village through CRHP-similar methods. Both these endeavors breathe of Gandhi’s hope for India, and even more his message for Sevagram. In 1945 Gandhi asked Dr. Sushila Nayar to begin a clinic for small infants and women in the village, in hopes of training village health workers and empowering the common Indian village to deal with the core health problems disproportionately affecting the rural population.

The reality is that India graduates roughly 30,000 doctors per year¹ yet hardly any can be found practicing in rural areas, all choosing urban centers instead. To try to curb this trend, the government has set up primary health centers for every 100 villages, creating an auxiliary nurse midwife to provide immunizations and monitor pregnant women, and instituting village-level traditional birth attendants for deliveries not done in the hospital. While this has created more jobs and more locally-available health staff, the effects have hardly been felt. A 2003 study in rural Maharashtra showed that only 12% of pregnant women receive the minimum antenatal care package, even though this is a service provided by the ANM.

To address the inequity in infant mortality and disease transmission, doctors are needed in the rural areas. Doctors are needed where health status is at its most fragile – in the rural village, not in a private practice in Pune. Doctors are needed where the majority of patients are, not where they could travel to, forcing them to miss work and pay unaffordable fees.

The success of CRHP empowering illiterate village women to reduce the prevalence of disease and sickness in their community has been made possible by the low-cost and supportive secondary-care hospital at CRHP Jamkhed that the village health workers can refer to. Without the hospital, patients would have to be referred to the district level hospital one and a half hours away and at times 2-3 times the cost for the same operation (for example–delivering via cesarean at the district hospital: 15,000 rupees or $300. At CRHP’s hospital: 5,000 rupees).

Even with VHWs, ANMs and TBAs, doctors are needed in rural areas to provide the necessary secondary and tertiary care that untrained professionals are not able to care for. Presently, when villagers have serious health problems, there seem to be three options: either they miss work and visit a hospital, they ignore the problem in the hope that it goes away, or they visit a traditional healer or village-level medical provider with no medical training who tends to give antibiotic injections for every complaint. There is little room for easy decisions and every choice has bad implications.

The department of community medicine has responded to this need by instituting programs to orient the students and provide them with a personal experience of rural life. Immediately after admission to MGIMS, first-years have an orientation in Gandhi Ashram for 15 days. Further, all first-years have to live with a family in a village for 15 days to carry out health, sanitation and nutrition surveys, returning each subsequent year for follow up. Finally, since 1992, it has been made mandatory that after medical school, new graduates serve for two years in rural villages, working with Institute-approved NGOs or in a government rural health center.

As I spoke with med students at MGIMS, I asked them what their plans were after graduating and completing their two-year rural fellowship. The first year students expressed their interest in staying rural and practicing medicine in the village. Answers from fourth and fifth year students: two wanted to be orthopedic surgeons, one an optometrist, and practically all said they planned to live in an urban setting. The attraction for doctors to urban life is just too great. If they are originally from an urban area, than they are practically foreigners to village life. If they are originally from a rural area, becoming a doctor is viewed as their way out. Being a doctor in an urban area pays more, as the patients tend to be wealthier and the problems more specialized. Plus, for their family, money is important, as they can now put their children into a private school and “give them a better future,” as one student put it.

Dr. Garg, head of the department, admitted that there is little in the village that attracts doctors to practice there. The education system tends to be worse and the government has set up no incentives to bring doctors away from urban life and into the village. Plus, as an outsider to the village, the doctor has to either find a house (difficult in a small village) or build one (which he/she tends to have little interest in doing). Perhaps the government should set up housing for doctors and compensate them to live in more rural settings? At what cost, though, must you motivate the physician to practice morality and equity? Whatever the solution, it must be accompanied by a change in the mindset of the physician to view medicine not as a lucrative profession but as the opportunity to meet the needs of the sick and enable the village to become healthy and productive.

Dr. Bang from SEARCH-Gadchiroli put it well when he told the story of Akbar and Birbal:

Akbar asks Birbal to find the ten most foolish men from his kingdom.

Birbal went yet was able to find only nine foolish persons; finding the tenth one was becoming a difficult task.

In his search for the tenth fool, he was walking up and down the road of Delhi. The road was in darkness except for a beam of light falling out from a window of a house. A man was bending and seemed to be searching for something. Birbal approached and asked him what he was searching for.

“I have lost my diamond ring and I am searching for it, and am not able to find it.”

“I can see that you are not able to find it. Where did you lose it?”

“In the forest, on the other bank of the Yamuna River.”

“Then, go and search there.”

“There is darkness there, while here there is light.”

The ring was lost in a forest, but it was being searched on a road of Delhi. Birbal found the tenth fool.

Dr. Bang followed by saying – unluckily, most of our medical research is done in this way. Health is lost in the villages but the research is done in the city, where there is light, facilities, air-conditioned rooms, but there are no problems.

Happy Hannukah! Merry Christmas! And a very happy new years!

Stalking Tigers on Elephants

I had already broken into my packet of Tums, trying to persuade my stomach to hold out the thirteen-hour overnight bus journey, when a man plops down beside me on the bed. On overnight buses, you are give a single bed instead of an upright seat, yet as he lied down beside me, giving me the odd look customary to when most see I am not Indian, I came to realize that this small single bed was two seats. Trying to sleep on a bus that is weaving through traffic, catching every bump, with a Bollywood soundtrack blaring from the speakers and a stranger snuggled up next to me is not easy. I turned, tried to get comfortable yet lay awake, wondering how it was so easy for the guy next to me to simply lie on his back, motionless, and fall into a deep sleep. Twenty seven hours and four bus transfers later, I arrived in Nagpur, then Seoni, then Mandla, and finally Kanha National Park, in the state of Madhya Pradesh.

We hopped into our gypsy safari the next morning at 5:30am, dressed in long sleeves and ready to head into the park and hopefully see some tigers. Kanha is a 2000-square-kilometer national park that regularly tops lists of the best places to glimpse a tiger. The park also lays claim to Rudyard Kipling’s Jungle Book, which is based on a case in 1831 of the capturing of a wolf-boy in the Seoni district. To attempt to see a tiger, we were armed with Santos (our knowledgeable driver), a British couple with two cameras and four lens attachments (one of which was bigger than my arm – “just in case the lighting was right,” he said), me and my Olympus auto-focus hand-held, and a guide who was bundled in five layers of clothing and didn’t speak for the first two hours due to the cold.

The park was fantastic as we drove through a virtually-untouched and overgrown forest, searching for tigers but running into hundreds of spotted deer, langur monkeys, peacocks, gaur (big buffalo), turtles, jackals (small wild dogs) and sambar deer. The rarest were the barahsinger deer, which can only be found in Kanha, and were useful since they howled to each other when they sighted a tiger. Seeing a tiger is no easy task and our driver would often stop in the middle of the road for thirty minutes (we could not leave the jeep), waiting to pinpoint the sound of a howling deer or monkey, and then racing over to the closest area to search for paw prints or listen for another hint.

As we gave chase, we ended up running into elephants who had located a tiger within the forest, so we climbed aboard these massive beasts and trekked out in search. As it was late morning, the tiger was already beginning to relax in the heat and we found her lying under some overgrowth, trying to get some sleep despite the huge elephants gathered around her with humans clicking away on giant cameras. We watched it lie there for some minute and then wobbled back to our safari jeep to let others get goosebumps too. In our jeep, we waited for the tiger to get up and walk around, following it down the road and watching it pay no attention to the fifteen jeeps stalking it as it headed down the road.

The next morning we felt not so lucky, as Santos camped out in the road due to the howling monkeys in the trees overhead but the tiger would not come into the open and show itself. After waiting for an hour, disappointed of not seeing one, we decided to head off in search of other animals, but as we drove we nearly ran over a huge male tiger crossing the road. We stopped and for a second were too stunned to even take photos. It went back into the forest, turned to look at us, decided it wasn’t interested, and continued into the forest. Considering the disappointed state five minutes before, the excitement was similar to watching Chipper Jones hit a three-run home run in the bottom of the ninth down by two runs, when you think the game is all but over and now you have newfound life and enthusiasm.

Kanha lasted only two days and before I could regain sleep I was back on the bus, this time headed to the Mahatma Gandhi Institute of Medical Sciences in Sevagram, where Gandhi set up an ashram and where he began the ‘Quit India’ movement. Traveling through Kanha was great, though, and trekking in open-aired jeeps searching for tigers and other animals was surely an awesome experience to say the least.