It has been almost a month since I joined Basic healthcare services (BHS) in Udaipur, Rajasthan. BHS runs clinics in remote villages of Udaipur to provide healthcare services to the tribal population, many of whom are also domestic migrant workers. These clinics are called Amrit Clinics and in this one month, I have spent a lot of time in here, just observing and understanding the people BHS works with.
While the nurses are available round the clock at these clinics, the doctors visit once a week. ‘Doctors day’ is when the clinics see upto 100 patients registered even before the ambulance from Udaipur arrives. Striking conversations with these patients, who sometimes wait for an entire day to meet the doctor, was not easy. I found myself constantly asking a few questions which clearly had become the conversation starters that I relied upon.
"Aap beemar ho? Kya hua?" "Aapka ilaaj kabse chaalu hua? Dawai lene ke baad thoda aaram mila?" "Aap kahaan se aaye? Kitna door hai clinic se? Paidal aaye kya?" "Aap theek se khana kha rahe ho? Din mein kitni baar khaate ho?"
I have avoided going to hospitals all my life. For the longest time, I’ve hated the ‘hospital smell’. The day I found out that I will be working with BHS, my biggest concern was around how I will deal with looking at and listening about illnesses on a daily basis. Never had I imagined that I would willingly choose to initiate conversations on diseases and/or medicines.
In general, which in this context means, outside the hospitals, I love meeting with and talking to new people. But here, it was different. Not only am I new here and find it difficult to follow the local dialect but anything that I could think of, a second later, I would feel that it’s not the most appropriate thing to talk about. Many of the patients who visit Amrit clinics, are suffering from Tuberculosis (TB) and are undergoing long-term treatments. Many are the mothers of malnourished children. Some visit with Malaria, STDs, skin diseases.
A lot of these patients migrate to other cities and states, in search of work, and hence, their lives were severely impacted during the lockdown. Asking them about their hobbies, favourite food or cracking a joke would all be inappropriate. My social skills were clearly not useful in interacting with this group.
I therefore decided to just tag along with the health workers while they were talking to a patient or counselling them. On a few days, I decided to join the group of women waiting outside the clinic, watching awareness videos on the importance of washing hands, or of family planning. After observing how the Community Health Workers or the nurses talk to the patients, I resorted to asking questions related to their health and nutrition.
Here are some of my learnings from multiple conversations I had, using the questions mentioned above:
- Lung diseases and medication: TB is a chronic disease affecting a large number of people. It requires constant care and a long-term treatment. The patients need to be nourished well as they tend to lose weight quickly. Before Amrit clinics opened in their villages, many of the patients used to go to private hospitals in Udaipur and parts of Gujarat, or even to quacks. These are not only expensive, but also put them on steroids. There is a lot of stigma around TB due to which many of these patients are asked to stay, cook and eat separately.
Silicosis is another commonly found lung disease in this area. It results from the inhalation of silica dust. Many of the patients who are migrant workers, have worked as stone cutters and have had high exposure to the dust. A lot of them have been receiving help from Aajeevika Bureau and Amrit clinics to register for the grant disbursement that they can avail. They are usually identified by Community Health Workers with symptoms like cough, and they link them to the clinic.
- Maternal care and family planning: Amrit clinics are located in areas where the primary health care centres either do not exist or are not functional. They provide facilities for deliveries and refer to bigger hospitals in cases of complications. Many women who would otherwise have home deliveries have been availing the facility at the clinic. Conversations on contraception happen with both men and women at the clinic and contraceptives are provided by the health workers. A person with a Sexually Transmitted Disease (STD), I met at the clinic was open to talk about it, and even brought his partner along for a check-up, which I found interesting.
- Nutrition: ‘Severe acute malnutrition’ (SAM) is a common condition among tribal communities in the Amrit clinic catchment areas. Given the poverty among these communities, the nutrition needs of families are often not met. Growing children, pregnant women, young mothers, and patients with chronic illnesses like TB, require healthy nutrition. Amrit clinics prescribe Ready-to-Use Therapeutic Food (RUTF) for malnutrition and also provide Amrit Ahar consisting of supplies like suji, soya and besan to TB patients. The BHS team has also made recipe videos using these materials. I showed them to patients waiting at the clinic, and had conversations on their diet. Many of them have only two meals a day and their diet usually comprises of wheat. Not many of them are aware of dishes that can be cooked with materials like suji. They are benefitting from the explanations and demonstration that are given at the clinic.
- Other illnesses: Since intake of all food groups in a balanced manner does not happen in case of most of the people here, they experience vitamin and iron deficiency, subsequently leading to Anemia. Malaria is peaking. I saw many weak young women with Malaria who were severely fatigued and were experiencing chills. Studies show correlation between malnutrition and malaria, with the latter further affecting the impoverished ones.
These are some of the realities in the catchment areas of Amrit clinics where tribal people live. Many of these hamlets cannot be easily accessed. Some can be reached only on foot while some others have narrow, bumpy roads. Of the people I met, many of them had reached the clinic after walking for 6-8 kilometres. This remoteness makes follow-up visits difficult.
Patients fear going to larger hospitals even if it is an emergency. On one of the doctors days, I met a family (about 6-7 people) of a pregnant woman, who strongly insisted on waiting outside the clinic for an entire day despite being told that there are no contractions yet, and the delivery might take a few days.
The conversation starters have been of great help. I could not have understood all this, if I had not used the words ‘Beemari’ or ‘Dawai’ in my first sentence. Having gained some sense about the context in which the clinics operate, I have now started going to the village to meet the communities, and can start a conversation with, “Namaste Bai ji, aapka gaon bahut sundar hai”.