India's road to health care still unpaved
By John Stackhouse
First published Sept. 13, 1993
In the torpid stillness of summer, when life ebbs and flows with each passing storm cloud, Biharipur's only link with the modern world of medicine strolls down the bullock-cart path, a white cooler of vaccines in one hand, a satchel of records in the other.
It is a rare visit by Sushma Singh, the auxiliary nurse and midwife who attends to the basic health problems in Biharipur and five other nearby villages. Mrs. Singh, who is supposed to call on each village every couple of weeks, has not made the journey to Biharipur in a couple of months.
Sometimes, she says, she did not feel up to the half-hour horse-cart ride and 45-minute walk across the rice fields crackling in the summer heat. Sometimes, she says, "other things came up." But now, she says, it is time to make up for lost ground.
As Mrs. Singh approaches Biharipur, a woman runs out of her hut carrying a baby, her eighth child, who is long overdue for vaccinations against polio, tetanus and measles.
"Where is your vaccination card?" Mrs. Singh asks.
"I have lost it," Chamba Devi responds, giving a wide berth to the buffaloes crowding her yard. "It blew away in the wind."
"How could you allow such a thing to happen?" Mrs. Singh snaps back in disbelief.
"Oh, it was a very stormy night," Mrs. Devi says meekly.
When Mrs. Singh plants herself in the shade to wait for the rest of the village's mothers, she realizes her own records are in shambles, too - the result of months of neglect.
Never mind, she says. Erasing the past, she proceeds to inject every child with new vaccines. Then, with a line of mothers still snaking down a narrow lane, she decides it is time to pack up her cooler, put away her files and head home.
Perhaps for another couple of months, Biharipur's vaccination program will be put on ice.
The insouciance of thousands of primary health-care workers such as Mrs. Singh has become one of the greatest health challenges on the front lines of development. It also has fostered a vibrant cottage health sector.
In Biharipur, where the government's road to universal health care runs broken and unpaved, two men peddle pills and vaccines bought in a nearby town, while a third comes occasionally to sell traditional medicines. Two women act as midwives. And a witch doctor deals with ailments more spiritual in nature.
"I don't know much, but I know enough to treat minor problems," said Prem Pal, a gawky teen-ager who sells medicines door-to-door, a trade he learned in high school, working after class as a compounder's assistant in Tilhar, the nearest town.
According to several recent studies, as much as 80 per cent of health care in developing countries is handled by private practitioners such as Prem Pal and Rajinder Singh Yadav, Biharipur's dean of quacksalvers.
As Mrs. Singh makes her exit, Mr. Yadav emerges for his afternoon rounds. The village school teacher, he doubles as medicine man, diagnoses the sick by feeling their foreheads and taking their pulses, a method he said he learned in the Indian army.
"There are only two things you need to know to stay healthy," Mr. Yadav said. "You test your nostrils by blowing. If the right one is clear, you need heat. You should eat food, take a bath and have intercourse. If your left nostril is clear, you need to cool down. You need water."
Walking through Biharipur's maze of lanes, Mr. Yadav treats a man with stomach pains by giving him an injection of oxytetracycline and some herbal medicines to drink, all for eight rupees (30 cents). At the next house, a girl is found shivering from fever. He gives her a shot of oxytetracycline, too, after washing the needle in cold water, and a few tablets of Vitamin B and chloroquine for malaria.
Next, a man with a bloated stomach appears. "Yes, you have worms," Mr. Yadav said, placing his hand on the man's abdomen. He doled out a few deworming tablets and, to be safe, gave the man a shot of oxytetracycline.
Biharipur's health problems are not surprising, given its landscape of cow ponds, paddy fields and a swamp that encircles the village. Every night is a feast for mosquitos carrying the cerebral malaria parasite. And with children defecating openly on their front porches and chemical fertilizers draining into the water table, the water supply is horribly contaminated, breeding gastroenteritis, polio and typhoid.
District authorities say they cannot keep pace. They have only one doctor for every 19,000 people and an annual medical budget of $50,000 for 1.8 million people.
"We can only provide for emergencies," said Dr. A. N. Khanna, the district's chief medical officer, who spends his days bobbing in a sea of files at the district hospital 30 kilometres from Biharipur.
Although health officials do not object to quacks, Dr. Khanna fears they prey on the illiterate, who make up three-quarters of Biharipur's population.
"If someone has a problem, they will just go to an unprofessional person," Dr. Khanna said. "They will not go to the public-health centres."
But illiteracy is only half the problem.
The state's sprawling health bureaucracy seems to have taken its own road many years ago, diverging more and more from those it is supposed to help. Each district still has a smallpox supervisor, even though smallpox was eradicated from the world in 1977. Each sub-district has an auxiliary nurse and midwife, but they often are afraid to venture to strange villages alone and on foot. Each village has a volunteer community health guide, but Biharipur's has been dead for three years.
As a result, the vast resources and technology committed to health care often do not reach home.
The birth-control pills and condoms that Mrs. Singh, auxiliary nurse and midwife, is supposed to distribute rarely arrive. Nor has anyone seen the supplies given to the village chief: chloroquine tablets for malaria, oral rehydration salt for diarrhea and chlorine for the dirty water wells.
As for the iron follic tablets to fight anemia and vitamin A tablets to reduce child blindness, the government supply to the district has been cut off for two years.
Without any semblance of training, the quacks make inevitable, and at times horrendous, mistakes.
Bagwati, a 60-year-old midwife who continues to deliver babies the way her mother did half a century ago, admitted to one a few weeks ago. A delivery - the woman's fourth - went horribly wrong when the child's head was too bloated to exit the womb. Not knowing what to do, Bagwati loaded the delirious mother on a bullock cart and drove her one hour to the nearest hospital. The half-born child died en route. The mother barely survived. "God had wanted it to be an abnormal birth," Bagwati sighed.
Despite the many flaws in rural India's public health system, there are some signs of progress, nowhere more than in the field of immunization. When Jagdish, 10, was an infant, his mother had not heard of vaccinations. He developed polio, as did his eight-year-old brother, Raju. "When our first two children got polio, we got scared," said Ram Beti, the mother. She then had her three other children inoculated.
But not by Mrs. Singh. Ram Beti and the children had to walk five kilometres to the nearest government clinic.