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A BOAT OF HOPE
Sanjoy Hazarika
Over the past four years, I have been privileged to lead an innovative health programme to reach basic health care on a sustained basis to lakhs of poor, marginalised people living on the thousands of islands on the Brahmaputra. The simple, effective and ambitious programme, which aims at improving their lives and giving them a foundation for major, positive changes, was first started in Dibrugarh district in Upper Assam and now covers nine more districts of the state in partnership with the National Rural Health Mission (NRHM). Not less than 2.5 million people live on these islands that dot the mighty river in Assam from its northern border with Arunachal Pradesh to Bangladesh in the south. The challenge is how to reach those affected by disease, and lack of access to medicines and healthcare in 2,500 of these chars or saporis—as these river islands are called in local language—since the government outreach has been grossly inadequate.
Most of these islands lack all basic infrastructure and services—from health to schools, power to roads, and water supply and sanitation. In June 2005, we at the Centre for North East Studies and Policy Research (C-NES) launched this unique initiative to bridge the health gap by designing and building a boat-clinic, called Akha—also described as ‘a ship of hope in a valley of flood’—to provide mobile health services to the poor and the marginalised on the river islands in Dibrugarh district. The focus has been children, pregnant women and new mothers as well as vulnerable adult groups.
Today, in a unique public-private partnership with the Assam wing of NRHM, we have expanded our services to nine more districts, including Dhemaji, Dhubri, Morigaon, Tinsukia, North Lakhimpur, Jorhat, Sonitpur, Barpeta and Nalbari, covering the major population groups living on the river islands, and there are plans to reach more districts. In addition, the project provides training and awareness on health, sanitation, livestock care and education in one of the most under-developed parts of the country.
Over one lakh people were treated under the programme in 2008. Our goal is to reach about three lakh people in 2009 and ten lakh by 2010, thus impacting one-third of the population, vulnerable to river and floods in the state. What is significant is that it is the first time in the history of independent India—and, one would presume, in the past centuries—that healthcare and other services are being provided on a sustained basis to these most vulnerable populations which are also geographically and socially excluded. Geographically, because they have no other connectivity with the outside world barring the river route, and socially because they are not just poor, but hail from marginalised tribal and backward caste communities, and minority groups further south.
Our goals go beyond basic health care. They include improvement of the maternal mortality rates (MMR) and infant mortality rates in these areas (because Assam has among the highest maternal and infant mortality rates in the country), and providing access to the care that can save and transform their lives. Nonetheless, it is one of the most challenging programmes because the health teams live on the boat itself as it travels from camp to camp. Each team on a boat-clinic comprises two doctors, a laboratory technician and a pharmacist. There are store rooms for medicines, a laboratory for testing blood etc. on board, as well as an emergency OPD below the deck in addition to cabins for the team, a kitchen and bathrooms. Often a cycle of camps covers several islands with one camp attracting anything between a few hundred to a few thousand people.
The organisation of the programme has been fine-tuned with local community workers setting up the dates for the camps and preparing the people, while the district administration and NRHM staff are consulted regarding the location of the camps and their duration. Every year, a specific work plan is chalked out to ensure coverage of a substantial percentage of the islands of the districts so that the needy are covered regularly. In rain or hot weather, in flood or in the dry season, when the going gets tough, our teams travel to the islands bringing hope and healing along the Brahmaputra.
We design the boats ourselves, for these are floating clinics. Noted columnist and writer Swaminathan A. Aiyar has donated funds for five such boat-clinics which are named after his family members. We built one from the award money won in 2004 from the India Development Marketplace of the World Bank which selected the best innovative ideas for potential rural change and bridging rural gaps. We are building four more boats in the new districts and are raising funds for the same.
Let’s take an experience in the district of Morigaon, not far from the state capital of Dispur, Guwahati’s twin town.
A small country boat is waiting at a 45-minute drive from the district headquarters to take us to an ongoing health camp on an island. It takes nearly an hour on the noisy bhotbhoti (motorised boat) to get there, and we take time to have a quick breakfast of boiled eggs and fruit.
The sun is up and the sand dunes are high on the islands here with the river split into many channels since flood time, which coincides with the annual melting of the snow, and the monsoon is still some weeks away. There are about six of us, including Sanjay Sharma, who is now a veteran at C-NES and is the Associate Programme Manager of the project across the state. There is Abu Kalam Azad, who is from Barpeta district, and is our district community organiser (DCO). The DCO is to the programme what the master (navigator) is to a ship—the most crucial member who charts out the programmes along with the district administration, the rural communities and the NRHM. He is the liaison man, documenter and the person tasked with ensuring the programme’s success and outreach.
I have been lucky with my teams here on this boat-clinics project and in other projects as well: they are good people with a strong grounding in rural realities. Some have worked with other NGOs, some with schools and colleges, and others are fresh out of university. The doctors are amazing—they work long hours, long days, day after day without any complaint and they are delighted with the outdoor work, with the chance to serve the poor and marginalised. We give them decent salaries but these are nothing compared to what they would earn if they were in private practice.
So, to those in this country and abroad who say that dedication is dead, or that people are not able to do the work that is needed in rural areas, I say, ‘That is rubbish! Come and see what the health teams are doing, how they work in such difficult conditions and how they bring hope and health to those who need it. And there isn’t a whisper of complaint except when they don’t get the medicines that they require from the NRHM and the health department.’
I am sure there are hundreds of others working in such conditions in many parts of the country, unheralded, unreported and unsung. But they get the work done and the media doesn’t do a damn thing about it. There are so many conversations I have had with senior television news channel leaders who have expressed interest in the work we do. But they have not sent a single team to cover it; not because they are not interested but probably because they don’t get the time to think about it. And here’s a wonderful media story about reaching the unreached. People who have never had access to health are getting it for the first time, and on a sustained basis. They lend themselves to visual telling and radio stories as much as print. In the process, we discover so much.
Like the women who come up to the doctors and say quietly they want family planning because they are literally sick with child-bearing; that these women are poor and from Muslim backgrounds should not be a surprise. Or the old man who came to a camp and watched for the whole day without saying anything. Noticing him, one of the doctors, Hafeez, asked if he needed a check-up. ‘No, I’m fine, I’ve just come to see what I have heard about: that health services are coming by boat, that there are doctors and nurses and that they are coming regularly. I wanted to see it for myself so I can tell others.’ These are enriching experiences. And they need to be shared.
As we reached the camp in the afternoon, it was already hot and sticky. I spoke to the doctors, the local accredited social health activist (ASHA) and villagers. Were there enough medicines, I asked the doctors. There were no supplies of IFA (Iron Folic Acid tablets), which are crucial to the health of pregnant women and a daily dose for over three months is the minimum requirement. The problems on the islands are obviously not what major challenges in urban areas are. These are waterborne infections such as dysentery and diarrhoea because even 60 years after independence less than 10 per cent of Assam’s population has access to a proper toilet and many residents do not have access to safe drinking water. Malaria and Japanese Encephalitis are the other major problems. These, in addition to poor diet because of residual poverty, lead to anaemia. There are also cases of mental stress in the islands because many lead a life that is extremely uncertain; at times, during the floods, they are displaced not less than two or three times, losing homes, relatives and livestock.
We deal with all these health issues through the boat-clinics and the medicine issues have been resolved because the NRHM team is supportive, responsive and transparent.
The image I carry with me of that warm evening is of Dr Zakaria sitting outside the tent and counselling the villagers—men and women—about the importance of family planning and the use of contraceptives. The audience listened in rapt silence and with keen interest, especially the women.
Things can change and we can make a difference. The key lies in quietly studying the issues, learning from others through listening, pressing the right buttons which can have maximum impact on the largest number of people through a simple intervention or a series of innovative steps which are rooted in common sense and an understanding of ground realities. The boat-clinics are an example of that powerful change which can come from an idea.