Written in 2015 during a fellowship year in Jawhar, Maharashtra.
Among the many problems that afflict rural India are inefficient healthcare and nutrition. On paper, it boasts a remarkable structure of primary and secondary healthcare centres and hospitals reinforced by auxiliary nurses, ASHA workers and midwives, not to forget various schemes to promote child nutrition. On paper only. Reality witnesses a number of hardworking individuals, fighting to dispense good health in a complicated system of interlinked issues, fuelled by the greed of corruption and the simplicity of ignorance.
Nutritional deficiencies start young
Anganwadis and primary schools carry a free midday meal scheme to introduce nutrition young, with kids being assured the quintessential balanced diet — rice, chapattis, dal, fruits and vegetables and milk — yet, kids are most often doled out a rice and dal khichdi sans other promised elements. Little wonder that malnutrition is rampant and is often manifest in frail, underweight and sometimes stunted bodies. Ration shops have experienced similar cuts in recent years. Where earlier, commodities like oil and sugar were also available subsidized, the shops now furnish only bare necessities like rice, wheat and dal (of steadily decreasing quality), necessitating the purchase of other supplies. With practically non-existent disposable incomes, most do without, perpetuating their circumstance.
Yet, it would be harsh to dump blame entirely on the government machinery since it appears that nutritional deficiencies are not sorely for a lack of trying. For example, teenage girls are distributed free iron supplements to combat the severe anaemia seemingly pervasive in this population, with monthly follow-ups and educational sessions to ensure that they are eaten. Dedicated nevertheless despondent nurses tell me that it’s a losing battle with girls more often than not deviously disposing the tablets and bringing back empty wrappers as proof of consumption. Short of force feeding them, what are they to do?
And then puberty hits
So if the shock of dealing with menstruation were not enough, most girls don’t have any clue as to what is actually happening to their bodies, nor the resources to find out. By the time puberty hits, they are out of primary school, away from home in ashram schools with no one to consult. One rather flustered principal tells me that his female students come to him completely terrified that there are differences in the extent to which they bleed as compared to their peers, in a conversation that I gather was not very comfortable all around. The only thing that seems to scare them more, is the matron they are left in charge of, who herself barely understands menstruation but is tight-fisted in her allocation of sanitary napkins.
Having said that, these children do receive comparatively better healthcare as compared to the average person living here. Annual check-ups complete with vaccinations, pregnancy tests, free medicines and supplements take place; what doesn’t take place is a conversation on the repercussions of unprotected sex. Thus, although there is no coercion and partners are often of their own choosing, for fear of pregnancy, a lot of parents choose to get their children married young before they become sexually active, and in effect prematurely terminating their education.
Structured healthcare doesn’t fare much better
As part of a preliminary resource mapping that we were conducting in a village, we invited discussion on the major issues they were facing. Government-bashing ensued. The salient points related to healthcare that emerged were that they were dissatisfied with the primary healthcare centre because the doctor speaks in Hindi and with their limited knowledge of the language they are not able to explain their conditions effectively; moreover, doctors and nurses refuse to prescribe medicines for their various ailments; when they do prescribe, they hand out less than that on the prescription, in all probability siphoning off the drugs elsewhere.
Further, the nurse whose duty it is to periodically visit each house and check on every person for illness prior to signing off outside the door, is a slacker. She signs off every month never having visited the houses at all. This becomes particularly irksome when women are expecting and go into labour at night. Requests to said nurse or ASHA worker for transport to the block hospital in Jawhar are met with instructions to wait until morning. “Delivery subah tak rukega kya?” they demand. Ultimately, they are forced to take private transport to the hospital costing them upward of Rs. 500, a sum they can scarcely afford and which by right, they shouldn’t have to.
Hospital workers have a different story to tell. Severely short of manpower and resources — primary healthcare centres don’t even have a water supply, let alone a disinfected one — they are struggling to meet the demands placed on them. Medicines from the government don’t come on time and when they do, are substantially less than that required. ASHA workers assigned to villages are not permitted to prescribe beyond the most basic of medicines and that too only for a maintenance period until the patient can arrange for a visit to the PHC. Doctors in turn express frustration that patients either come in for every little twitch and scratch that doesn’t require treatment at all, or they experiment with therapies offered by local vaids (mostly quacks) and don’t come in till their illness has progressed significantly.
Is it ignorance which clouds judgement?
An NGO colleague has an interesting theory as to the cause of the latter. He has observed that people place greater faith in the local vaids because they attempt to foretell their patients’ conditions and recommend suitable treatment, which surely suggests greater prowess than a doctor, who despite years of training still asks you for symptoms prior to suggesting treatment.
There is raging frustration within the healthcare system all around which is immediately palpable when you talk to anyone involved, but nobody seems to have a readily available solution. Off the bat, it seems to me that there is a communication gap and a lack of accountability that is exacerbating the problem. While the latter is something I have resigned myself to, there appears to be scope for intervention in the former: perhaps, better information dissemination to youth, particularly girls, or a platform for more reasonable dialogue between doctor, nurse and patient? Maybe a system of accountability for nurse duties and medicine dispensing that relies on checks by the community itself? Then again, all that’s probably just wishful thinking.